Back Pain and Babies

Dr. Diane Benizzi DiMarco

 (reprint)

The physical stress of parenting or caring for infants and young children can impart tremendous biomechanical strain. Parenting and care taking can be done by both genders but remains a female dominant task. Daily repetitive stress from tasks that require lifting the child or infant can compromises spinal integrity. Repetitive injury to the disc, zygapophyseal joints, muscles and ligaments of the spine can result from chronic lifting, twisting and torquing, and poor posture.

The post partum patient retains a higher risk for potential injury as compared to the patient who has not endured pregnancy or has not been pregnant for an extended period of time. Fertilization propels the release of estrogen, progesterone and relaxin, hormones essential to the growth and development of the embryo and fetus. These hormones that are essential to the pregnancy cause global relaxation to the ligaments and muscles in the female pregnant patient. A conglomerate of anatomical changes created by the global laxity in muscles and ligaments compromises the stability of the spine.

Spinal stabilizers, such as the abdominal muscles, lose their tone and affective ability to counteract the increasing lordodic curve. The zygapophyseal joint, the pelvis and ligaments and muscles surrounding the spinal column, lose their ability to stabilize the spine. Throughout the pregnancy, instability gradually increases. As the pregnant female proceeds from the first trimester to the third, postural adaptations can be noted. Often patients develop a transient cervical curve reversal, a posterior shift of the center of gravity to the heels of the feet, a hyperlordosis, hyperextension of the knees and a hyperkyphosis. As abdominal girth increases, excessive pressure is placed on the lumbar lordosis and the zygapophyseal joints.

These patients proceed through pregnancy with some experiencing back pain and some not. All, however, experience a change in there anatomy. Once hormonal homeostasis is reached, post-partum, global hardening of ligaments and muscles occurs. Patients may at this point begin to discover back pain previously not felt. Those who are tending to infants and small children may find themselves lifting and holding a toddler or infant for extended periods of time. Chronic contraction of the ipsilateral muscle of the arm, forearm and upper thoracic region can irritate an existing condition. Post partum women that have lax tissues and hypermobile spinal segments increase susceptibility to injury. This does not exclude injury potential to non post partum patients. Those without the concern of ligament laxity are exposed to injury potential from continued and chronic use of those muscles.

During the transition of post partum, hormones begin to reset. This event is the prerequisite to re-hardening of muscles and ligaments. The sacrifice of spinal stabilization that allows for growth and development of the fetus exposes the mother-to-be to an increased probability of back injury. Adaptations in posture, during pregnancy causes a posterior shift in the center gravity. Stabilization of the spine relies more heavily on the posterior joints. Asymmetric movement and altered biomechanics caused by hypermobility in the joint may result in adhesions about the zygapophyseal joints where re-attempts to stabilize the region becomes preemptive to spinal osteoarthritis.

Discogenic injuries can cause low back pain in women of childbearing years. The increase in ligament mobility and loss of muscle tone that creates hypermobility in the spinal segment may affect the material of the disc. The annulus fibrosis is designed to resist forward translation while containing the nucleus pulposus. Such architecture can be compromised, thus interfering with axial absorption, a function of the nucleus pulposus.

New mothers who are post-partum often resume the routine of child-care without obtaining full recovery. Laxity of the ligaments and muscles remains. Often mothers are lifting car seats, baby strollers, the child and/or other siblings into their arms and carrying the infant and other children. Many times this is done with reckless abandon to proper back ergonomics. Mothers are often fatigued and hurried to get to their destination, often with self-neglect. These activities, concurrent with laxity of muscles and tissues, create a canvas for injury to the tissues around the spine.

Patients who are caregivers, such as grandparents, nannies, adoptive parents and child care workers, are a population that too retains a high risk for back injury potential. These patients perform the repetitive movements common to care taking small children. When evaluating these patients for spinal injury, it is also important to consider their age. Grandparents and older care-givers may injure muscles of the spine, irritate an existing condition of spinal arthritis, or develop a new injury to the ligaments muscles or a bursar. Patients who are younger, those in there twenties, thirties and forties may easily injure the intervertebral disc as well as the spinal joints and tissues of the spine.

Post Partum and Beyond: Managing Back Pain

There are factors that contribute to post partum back injury beyond the obvious biomechanical strain of pregnancy and caring for young children. Women with depression, a c-section, experience chronic fatigue, have compromised nutrition or sub-clinical vitamin/mineral deficiency, or who are ill may be at an increased risk of back injury.

Depression:

Post partum hormonal fluctuations can result in the clinical state of depression known as ‘post-partum depression’. Not all women experience post-partum depression. From pregnancy to pregnancy and delivery to delivery a woman’s biochemical response can differ. Postural faults can give way to identifying a potentially depressed person. Women with a downward head tilt, a flexed cervical spine and rounded shoulders may be showing signs of depression. Depressed patients tend to abandon proper lifting techniques, exposing themselves to further injury. Conversing with post-partum women can aid in identifying the possibility for depression. Inquire about her social networks, family, church involvement, friends, and organizations to which they belong and could reach out for support. Refer patients for counseling as indicated.

Depression can affect young mothers, stay at home parents, or non-parental caregivers. Adults who choose to stay at home whether they are the parent, a family member assisting in child care or are employed as a child-care worker may experiences feelings of isolation, frustration, or feelings of being overwhelmed. Young mothers, fathers, or grandparents who formerly had a career, freedom to dine out, or enjoy entertainment, otherwise find that they have demands and responsibility that may require around the clock attention. Parents, veteran or new may have a new baby who is colic, sick, disabled or requires extensive medical attention. They may also lose touch with friends, hobbies and social calendar events. This can truly have a devastating affect. As health care providers, it is important to offer a pool of information regarding where they can seek peer interaction and professional guidance. Encourage these patients to stay active in their health. Clinicians can suggest that patients seek out their hobbies as a business that can be conducted from the home or residence to suite their schedule, such as crafting, wood working or writing. Guide them to join church groups, mothers groups or township organizations that will provide a social network and peer interaction.

Depression can also be associated with issues of weight. After childbirth, a myriad of females are affected by this. Many patients who are primiparid may unexpectedly find that after the delivery much of the weight gained during pregnancy still remains. Patients who are normally lean and thin may have a difficult time accepting this condition. Reconditioning these patients and maintaining proper posture and alignment can help augment a sound and healthy weight loss program. By avoiding injury, they can maintain an exercise curriculum that will restore health and aid in weight management. Exercise can also stave off depression through endorphin release. Exercise parameters should be discussed to provide adequate guidelines in health restoration.

Patients who have had a cesarean delivery have a longer recovery period. They have had several layers of abdominal muscle and fascia and ligaments resected. Depression may ensue do to an inability to resume their regular activities due to difficulty in mobility, and increased abdominal weakness. With each pregnancy that results in a cesarean birth the muscles of the abdomen become weaker. Permission from the obstetrician should be obtained prior to implementing an abdominal strengthening program. Patients should be consistent and moderate in their exercise until full recovery and strength is resumed. Yoga and pilates are viable options for regaining core strength and muscle stretching.

Fatigue:

Lack of sleep, new demands from the infant, breast feeding on demand and tending to other children, household chores and spousal needs can be exceedingly demanding. Techniques in lifting and reconditioning may not be implemented as required. Initially the most important aspect to recovery is to regain health and acquire as much sleep as possible. For many this requires the assistance of family and friends. Advise patients to acquire as much help as possible to facilitate the sleep they require. Other sources of fatigue include anemia, illness, chronic fatigue syndrome and metabolic disorders, especially thyroid disease.

Fatigue

New mothers/caregivers usually have no time off from work; they do not have any sick time or disability. Often fatigue becomes severe with chronic sleep deprivation. Whether caring for a newborn infant, toddler or adolescent time becomes a commodity. Nutritional compromise in mothers and care-givers is common. The demands of child-rearing often time interferes with preparation of proper well balanced meals. New parents often eat sporadically many times not even sitting to eat a meal. Moms may find that they accidentally miss a meal, only to indulge in non-health foods laden with refined sugar, saturated fats and additives when overwrought with signs of hunger… These types of eating habits can cause fatigue or exacerbate an existing condition of fatigue. In addition to having an important social network that can help facilitate wholesome meals and time for the caregiver to rest it can also serve as a support for weight control. Women who are beyond childbearing or have not experienced pregnancy may too be afflicted with improper dietary habits, a hectic and demanding schedule, stress, illness or going through a life change. Each of these women can benefit from improved eating and healthier options.

Fatigue may be an outward signal of anemia, thyroid dysfunction, or illness. According to the extensive research of Dr. Broda A. Barnes, many patients suffer from a sluggish thyroid although blood tests reveal no abnormalities. (1) He professes that recording the axillary temperature can identify a thyroid problem. See his research for further information. Patients should be advised to supplement there diet with whole food multivitamins, adequate water ( protein shakes made with water or water with lemon and stevia ) and essential fatty acids vitamins and obtain as much rest as possible, whenever possible. Muscle injury and fatigue can often be aided with proper nutrition, stretching and ergonomics. Other nutritional support for fatigue includes but is not limited to: B-complex vitamin, CoQ10 supplements and iron ( with anemia, especially women who are menstruating) supplements.

Patients who present with debilitating fatigue should be referred to their primary care physician for a full blood chemistry to include a thyroid panel, ebstein barr virus, lymes disease and cancer. Co-treat the patient and request a copy of the blood chemistry report.

Pain:

During gestation, some women may experience a decline in pain perception. It has been postulate that, as hormones are released through the pregnancy they mute pain perception. As hormones levels are reestablished pot-partum, the patient may experience a return in pain perception. Patients may experience musculoskeletal pain not felt through gestation. The re-setting of hormones to a non-gravid state is the catalyst for ligaments and muscles to regain normal elasticity. According Grey’s Anatomy a manual adjustment may be indicated to prevent mal-articulations as the hardening of the ligaments occurs. Grey’s specifically indicates that this might be particularly necessary with re-hardening of the sacroiliac ligaments. An omission of manual manipulation may cause a re-positioning of the sacrum that can result in chronic low back pain. (2) The resumption of normal ligament laxity for new mother’s is often congruent with reports low back and sacral pain not felt during pregnancy.

Thoracic pain is also common in post-partum mothers as well as care-givers. The continuous need for the newborn to be held imparts adaptations throughout the spine. The most profound affect can be to the thoracic spine. Multifactoral etiologies include: engorged breast tissue, rounded shoulder posture, and ergonomic compromises seen with lifting and carrying infants and small children. Paraphernalia to accommodate these needs will be discussed in further detail later. Ergonomic faults during the feeding process, for both nursing mothers and caregivers who engage the newborn in bottle feeding, result in a round shoulder position with either a reversal of the cervical curve or extension of the occiput on atlas and flexion of the lumbar spine. These postural changes can result in thoracic and cervical pain.

Patients should be encourages to nurse or to bottle feed the infant in a seated position. She or he should support the low back by placing a step stool or thick book under the feet, place a pillow or other support under the arm supporting the child’s weight, and if bottle feeding to support the arm that is holding the bottle. Remind them to switch arms with each feeding. There are many devices available at “baby” stores that are designed to support proper ergonomics to parents and caregivers. Maintaining good and proper posture remains at the forefront of back pain abatement. Encourage patients to investigate which is right for them. Special support pillows known as ‘boppy pillows’ are available for this use, though any home decorative pillow or bed pillow will do.

Cervical pain may ensue when patients have poor posture; when phone use is congruent with holding baby/child; and when patients engage in multitasking while holding the child or infant. Phone use while carrying the child/infant encourages a shoulder to ear position. This causes excessive contraction of the trapezious muscle, the levator scapular muscle, as well as the ipsilateral muscles of the cervical spine. Patients who adorn a child on their shoulders reflexively flex the cervical spine while holding the child above their head and resting on their shoulders.

Studies by Dishman and Bulbulion support evidence of pain amelioration post adjustment. (3,4) Such evidence strongly indicates chiropractic as a treatment approach. Patients should also be educated regarding proper posture and ergonomics. Educate patients to do moderate neck rolls, stretching the pectoralis muscles. Encourage the use of hands free phones that discourage the shoulder to ear posture, to switch the phone from the left to right ear and vise versa and to refrain or minimize carrying the child on their shoulders.

Baby Paraphernalia…good or bad?

Armed with a conglomerate of items needed to raise an infant safely, parents and caregivers become encumbered by awkward positions and bulky items to carry.

Removable infant car seats cause the caregiver to perform a repetitious lift and torque motion resulting in discogenic injury. Repetitive injury to the annulus fibrosis causes micro tears in the annulus fibers. Perpetuated, this may result in tearing of the annular fibers with bulging or herniated the pulposus. This phenomenon is most common in individuals 25 to 40 years of age. Muscles and ligaments of the spine are not immune to the insult of asymmetric repetitive motion. Sprain/strain injuries to the ligaments of the spine and the muscles as well as injury to the facet joints are common.

Removable infant car seats are designed to face the rear or back of the car. The child can either be removed from the seat or removed with the seat, while still being safely strapped within its’ confines. The mother/caregiver who chooses to remove the entire car seat with child is exposed to aberrant posture and lifting motions. Removing the infant and car seat simultaneously is common when the infant is sleeping and does not transfer well out of the seat to a crib. It is also common to remove the infant within the car seat when the infant cannot hold its’ head erect or cannot sit up in a seat provided by a shopping wagon or again, if the infant is a sleep. Patients who engage in the repetition of removing the car seat with the infant should be directed on proper postural form with removal and carrying of the car seat. Be aware that many women/caregivers carry the car seat and infant to their destination. An infant who weighs 12-15 pounds and a car seat that weighs 10-15 pounds can impart excessive biomechanical stress to the spine. Many choose to hold the seat by the handle causing a swinging action on the side that the seat is being held. Patients also tend to lean to the contralateral side of the side holding the car seat. The repetition of this attempt to counter the encumbrance of the car seat can result in wear to the spinal joints and muscle injury.

Encourage patients to hold the car seat as close to their body as possible and to lift the car seat close to the body using both knees and not her/his back. Employing the use of ‘snap-n-go’ strollers and to use shopping wagons that allow for safe placement of the infant car seat can further reduce repetitive trauma to the spine and its’ surrounding tissues.

Educate patients on the proper removal of the infant car seat. Explain that removal of the seat should be done from the back seat of the car. Unlatch the car seat and place it on the seat of the car. Remove the infant car seat after they have exited the car and are standing perpendicular to the opening of the car door. At that time they should pull the seat as close as possible to them and lift the infant car seat as straight as they can and as close to their body as feasible. This will minimize the torque that is common when attempting to quickly remove the infant seat. Mothers/caregivers normally lean over the back seat from the back car door, unlatch the seat and proceed to lift with outstretched arms, to carry the seat or place it where they intend. Continued repetition of this spinal abuse can result in spinal injuries including injury to the disc.

Baby bathtubs

Most often on initial home bathing, the infant is washed in the sink. Due to the height of the sink, this task is gentle on the posture. Advice patients to be fully prepared with soap, towels wash cloths, diapers and ointments. Instruct them to place them in an ergonomically convenient place. As wet infants are extremely slippery, some may wish to purchase a foam or rubber insert for the sink. most of which can be used in the larger bathtubs. Patients can also use a step stool to alleviate the low back pressure from standing. Advise them to place one foot on the stool while performing their task. Once the bathing is done the patient should remove the stool to avoid an accident.

A child that is too large for the sink graduates to a baby bathtub. The bathtub is normally inserted into the adult tub. Although much safer for the infant, this encourages the mothers/caregivers to be in a kneeling position over the tub, assuming a hunched position for extended periods of time and on a daily basis. The use of a ‘kneeling’ chair may aid in obtaining a more correct posture.

Removing the baby/child from the tub may compromise spinal and postural integrity with a torque and lift motion. Educate patients to remove the baby/child with a straight back while lifting the baby as close to her body as possible.

The adult caregiver, at this point, will probably be in a kneeling down position. To avoid back strain, the adult can either lay the baby/child on a padded and clean bathroom floor to diaper and dry, or the adult can lift herself with the child in her arms, using her knees. The child or infant should be held close to the body to avoid back strain. The child/infant can then be brought safely to a changing station. Using a supportive structure while obtaining an erect standing position can be accomplished by leaning on the tub or sink. This too will lessen the pressure on the low back. 

Changing the infant/toddler can often result in a forward flexed thoracic spine with a flexed cervical spine. Changing tables can aid in minimizing the effects of this. Changing table are preferred and recommended in lieu of using of the crib. Diaper changes in the crib can commonly cause the attending adult to assume a forward hunched over position. This is because the crib mattress is usually set lower than that of the changing table thus requiring the adult to hunch forward to a greater degree. Changing tables are at a more convenient height so that the infant/toddler is at approximately chest height. Amenities that encourage ergonomic placement of diaper, wipes, creams, powder and diaper pail can be found at stores that cater to infant needs. The changing table should be used as long as possible, assuming its safety outweighs is potential danger, the weight of the child exceeding the tables’ load capacity, or the child falling off.

Advice patients to remain conscientious while holding the baby, nursing the infant, changing a diaper or dressing the baby/infant, all can create postural compromises that can insult the integrity of the lumbar spine while creating a repetitive rounded shoulder and cervical flexion posture.

Spinal therapy should focus on proper intersegmental mobility to these regions while incorporating ergonomics. The lumbar spine is also a concern. Reducing pressure on the lumbar lordosis can be accomplished by using a stool for one foot, thus increasing lumbar alignment and reducing low back strain. Since an infant/toddler is changed several times per day, patients are in this position numerous times. Employing back supporting activities can assist in the reduction of disc, zygapohyseal joint and muscular injury, and enhance the results of rehabilitative exercise. Employ patients to take the time to do cervical stretches such as range of motion exercises. The same is recommended for the thoracic spine. Encourage patients to retract the scapula and to stretch the pectoralis muscles.

Play Pens

Play pens offer safety to an infant when the mom needs to be ‘hands-free’. Prevention of back injuries is often compromised while placing and removing of the infant or child in the play pen. Commonly the child is placed down into the play pen while the adult is in a flexed position. This flexed or hunched position is repeated when the child is removed. Outward stretched arms create a lifting motion that compromises the upper thoracic region. Repetition can injure the upper and middle trapezious muscle, rhomboids and levator scapular muscles. Lowering one of the side bars would be ideal in ameliorating injury potential. As of 2005, no play pens or ‘pack n plays’ are available with this accommodation. The lowering of one of the side bars would cause a collapse in the play pen. Potential hazard also exists if the adult does lower the side prior to placing the child in and after re-securing the side bar with an abrupt, jerking and snapping motion. Injury to the digits and or entire hand can result if the child places his hand near the adult if the child is seeking to be removed.

High Chairs

High chairs provide a convenient and safe way to feed and entertain a baby. Unfortunately for the adult who places the child or baby into and removes the child out of the high chair, it can actually hinder proper lifting techniques. Most high chairs are designed so that the front table of chair is removable, allowing for easy access to the seat. Once the front table is removed, the adult can seat the baby and buckle her/him. This can be done with the adult perpendicular to the high chair and at close proximity. Twisting and lifting at obscure angles can be avoided. After the baby is buckled, the front table is reattached. Simple as it may be, this ritual can become long and tedious to the adult who is anxious to seat/remove the child. Compromise is often seen in haste. The adult will forfeit removing the table and opt to place the child or baby into the chair by lifting her over the table and into the seat. This procedure will usually cause the tending adult to outstretch his or her arms and lift or lower from there. Advise patients to avoid this aberrant motion and to succumb to the arduous task of removing the front table with each sitting.

Carrying the Child

How a patient carries the infant/toddler and what he/she is doing while carrying the child is important as a mechanism of injury. Patients often favor one side over the other. The dominant side may not be the side that the infant/toddler is held. It is common to find that the dominant hand is reserved for tasking. Those who are right hand dominant have a higher propensity to carry the infant/toddle on the left side. This leaves free the dominant hand free to do chores. The postural adaptations assumed while carrying the infant/toddler usually will include jutting of the non-dominant hip while maintaining a contracted arm position at approximately seventy-five degrees abduction. The arm is bent at the forearm to securely hold the infant/toddler. This creates a repetitive strain on the muscle of the upper thoracic spine.

Carrying the infant/toddler is commonly done while multitasking. The mother/caregiver may habitually carry the child on same arm and hip so that she or he can perform other necessary tasks. Women/caregivers who need to tend to household chores such as cooking, vacuuming and dusting may attempt these activities while holding the infant/toddler. Talking on a cordless telephone, while carrying a child is a common activity. Cervical ipsilateral lateral flexion to the ipsilateral shoulder with the shoulder lifted upward allows for holding of the telephone free of hands. Cervical compromise can be observed. During a focused patient history, it is important to inquire about the activities of daily living. Ask your patient if he/she uses a hands-free phone, or if he/she talks on a wireless. The use of wireless phones encourages longer conversation. Without the restriction of the wire, patients are free to move about and accomplish tasks around the house. They are also prone to engaging in conversation while changing the baby, feeding the baby (either via nursing, a bottle or even at the high-chair), even while just holding the child. In addition to performing a focused history, be aware, a focused history can turn into an educational consult. It is here where you can advise your patients of viable alternatives, ergonomics, stretching and the importance of spinal adjustments as a way to maintain joint mobility and spinal integrity. Be sure to check for leg length inequality, a posterior or rotated sacrum, hypertonic erector spinae muscles and myofascial trigger points in the quadratus lumborum muscles, myofascial trigger points and/or hypertonic rhomboids, traps, levator scapulae, cervical muscles and sub-occipital muscle. Palpate for segmental dysfunction in each region as well as myofascial trigger points and hypertonic taught bands.

Carrying Options

Myriad carrying options exist for care givers. Front carriers, back carriers, and side carriers are now available in various sizes and designs. Although they seem like a viable option with symmetrical weight distribution, tremendous stress can be imparted on the musculoskeletal system. Front and rear carriers can compress the shoulders bilaterally causing a constant depression. Side carriers compress the shoulder it rests on in the same manner the front or rear carriers do. Patients may try to compensate for this by lifting the shoulder upward. Contraction of the ipsilateral trapezious muscle, levator scapulae muscle can cause sprain/ strain to the tissues. To accommodate the extra weight to the anterior or on the dorsum, weight distribution and the center of gravity shifts. Patients will shift their center of gravity to the anterior for rear carrying child supports or to the posterior for forward carrying child supports. Front carriers can cause patients to insinuate a posterior shift, mimicking that of pregnancy. Chronic shortening of the lumbar muscles with an increase in the lumbar lordosis may cause a facet syndrome with possible myospasm or myofascitis of the surrounding soft tissue. Carriers designed for the dorsum encourage patients to adopt a forward, anterior lean with thoracic flexion, bilateral anterior rounding of the shoulders and a compensatory cervical extension or possibly a cervical forward head carriage.

Carriers with side carrying options offer a viable option to holding an infant. This method of supporting an infant requires the use of a ‘sash’ type of carrier that swaddles the baby in a cradling fashion. It wraps across the chest and abdomen of the adult and to the posterior across the back. Downward pressure is exerted on the ipsilateral shoulder that the sash is resting.

Individuals should be encourage to research the most ergonomic and comfortable form of support for them. Instruct patients to avoid spinal compromise and opt for the carrier that maximizes spinal integrity, distributes weight evenly and incorporates the hips for additional support and balance.

A focused health history of mothers/caregivers should include inquiry regarding the use of carrying devices. You may also suggest the patient bring the support carriers in to the next visit to examine postural adaptations and possible faults.

Proper Ergonomics with Stroller Use

Purchasing a stroller can be overwhelming to new parents. Bombarded with amenities it seems that even a college degree may not be sufficient. Assisting patients in choosing a stroller may alleviate some anxiety along with saving themselves from back pain and money spent. Child safety is at the forefront when purchasing any piece of equipment intended to aid child rearing. Ergonomic consideration for the adult should be receiving as much attention. Strollers are often designed that when the adult pushes the stroller a hunched position is acquired. Advise patients to look for a stroller with handles that are high enough to avoid hunching. They should make sure that the wheels move easily and turn with little effort. All of this will abate the need to hunch and push the stroller with excess pressure on the back. Other amenities such as cup holders and pouches are important to carry bags. This will free up the hands and arms.

Exercise and Weight Control

Exercise for women post-partum or otherwise is an excellent way to attain cardiovascular health, control diabetes, decrease symptoms of menstruation and menopause, and obtain overall health. Weight gain for women is a common battle. Post pregnancy weight and weight gain from menopause can be controlled and reduced with an exercise program and healthy food choices. Women who are menopausal, pre menopausal and post menopausal are encouraged to include weight bearing exercises to combat bone resorption. Proper exercise can reduce fatigue while boosting metabolic rate, self esteem and mood.

Recreational physical fitness that becomes obsessive can be deleterious to a women’s health. Female athletic activities such as running, swimming, and varied aerobics help facilitate the goal of weight loss and muscle tone. The caveat is when women calorie restricts and exercises to excess.

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