Confessions of a Virtual Physical Therapist

The world has been turned upside down by COVID-19 and the world of physical therapy has not been spared. As a physical therapist who has worked with patients from the tech-driven Bay Area for over a decade, I have educated and helped many patients improve their computer and workstation ergonomics through postural corrections, equipment changes, and by modifying activities  to improve a patient’s pain and dysfunction.

As COVID-19 virus literally went “viral”, Therapydia made the tough decision to close our doors to in-person visits in accordance with San Francisco’s Shelter-In-Place Order. We, as a team, also thought it would be better for the general health of our region if we did not become vectors for virus transmission to our patients and families. With that decision, our team had to make a quick turnaround to providing our services over virtual platforms. And with that transition, we “active” PTs used to working in a clinic had to set up laptops at home and figure out optimal ergonomic setups–some successful, some not!

As we set up our virtual clinics and began more than usual hours in front of computer screens, we all began feeling similar symptoms as those that our patients would report to us over the years!  Just like our patients, we didn’t have proper office chairs and are now working for extended periods of time at our kitchen counter or hunched over a coffee table–positions that it are not ideal for our bodies and overall health. Fortunately we could utilize our extensive knowledge of biomechanics and ergonomics and finally put our student loan money to good work on ourselves! We have begun to walk in your shoes and now present to you  our confessions and our solutions!

PT Confessions:

Greg Ohanessian, PT
Therapydia Embarcadero

Low back pain from sitting in a flexed posture:

My dining room table looked like the best place to set up my home office. Unfortunately, my dining room chairs are lower than I thought and my hips were positioned at the same height as my knees, leading to a posterior pelvic tilt. This flexed my spine more than usual which increased stress and strain on my lumbar spine discs. As I stood up I noticed an increase in pain in my low back.

Solution:

1)Find a taller chair to have my hips above my knees to lessen the flexion load on my spine
2) Sit on a pillow to raise my hips above my knees

If you’re working from home amid the COVID-19 pandemic, you might find that your makeshift office is a literal pain in the neck. Check back often for more solutions to combating aches and pains from transitioning to working from home.

3 Common Electric Scooter Injuries & How To Prevent Them

electric scooter injury prevention

If you live in San Francisco, you can look out your window to see dozens of people zooming by on electric scooters. Over the last year, the usage of these motorized scooters to get around the city has exploded with their ability to go 30 mph coupled with a riding range of 20 miles, making these scooters ideal for commuters and weekend warriors. However, with the increase in ridership comes an increase in scooter-related injuries.

Over the last five years, scooter-related injuries resulting in hospitalization have more than tripled nationwide. Recently, I had a patient who can be described as your typical “Tech” worker who had a fall off of a Scoot in the most “San Francisco” of ways.

Our patient was commuting to work on his Scoot when the car he was following came to a stop in the right lane. The patient noticed the stop and decided to whip around the car on the right side in the bike lane. What our patient didn’t notice was that this car was an Uber. As he began to pass the car on the right, the Uber passenger opened the door and struck our patient. When our patient was struck he fell off his scoot and onto a parked Tesla! Thus sustaining a clavicle fracture from the trauma of the incident. Does it get any more San Francisco than that?!

Dr. Sara Edwards a local, prominent orthopedic surgeon and Therapydia referral source has seen a recent uptick in Scooter injuries in her practice that correlates with the increase in ridership. According to Dr. Edwards, most of the scooter injuries that she sees occur in the extremities including shoulder, wrist, ankle and knee bone fractures, along with soft tissue injuries that usually require surgery. Head injuries are of concern as well due to riders not wearing helmets during shorter rides. Dr. Edwards has also observed many injuries that occur due to scoot riders scooting while intoxicated.

Accidents Happen

Though accidents like the one detailed above are rare, accidents do happen. Here are a few common scooter injuries and how to prevent them:

Head Injuries: Concussions and other head injuries are common among riders who have accidents without wearing a helmet.
Prevention: The best way to prevent head injuries is to ensure that you wear a helmet every time you ride.

Riding While Under The Influence: Being under the influence of alcohol while riding
Prevention: Simple don’t do it!

Shoulder and Wrist Injuries: Traumas from falling onto outstretched hands
Prevention: Speak to a physical therapist regarding proper fall technique. Learning how to fall and roll will lessen the impact.

Lower Leg injuries: Bracing/braking injuries if scooting too fast.
Prevention: Slowing down your scoot is the biggest preventative measure here. When stopping making sure your feet are positioned safely so the lower legs don’t sustain excessive forces.

Injuries are prone to happen with all types of transportation modalities. With our ever-evolving transportation modes here in San Francisco and other big cities as well, Physical Therapists are ready to help collaborate with orthopedic surgeons in evaluating, treating and returning our patients to Scooting.

Get To Know Your PT: Jonathan Lim Sze How, PT, DPT

Jonathan Lim Sze How PT, DPT

Physical therapist Jonathan Lim Sze How takes some time to share his favorite ways to stay active, how he knew physical therapy was the career path for him and what he listens to to get pumped up.

 

“Gradually challenge yourself to do more and more, you will be able to achieve anything.”

 

When did you know that you wanted to be a physical therapist?

I always knew I wanted to be in a profession where I could be actively help people, while not having to sit behind a desk all day long. I realized during my undergraduate education how amazingly complex and resilient the human body is while learning about anatomy, physiology and biomechanics. This pushed me to learn more, become a human movement expert and help others, thus pursuing physical therapy as a career.

What’s your favorite song to get you motivated?

Any classic 90s rock song!

What is the biggest challenge involved in being a PT?

One of the challenges we face, in my opinion, is that our patients often take too long after sustaining an injury to come in for a consultation with a physical therapist. Often this can delay their recovery process while causing other compensating issues to surface and complicate things.

How do you like to stay active?

I became quite an avid runner over the past several years. I love the feeling of just being on my own and challenging myself both physically and mentally. When I moved to San Francisco, I got into trail running and started exploring the countless number of beautiful trails the Bay Area has to offer.

What surprised you the most about the physical therapist profession?

I was gladly surprised by how far reaching our profession is. You can find physical therapist’s working with newborns and their parents in the in neonatal units, or getting ICU patients who hooked up to several machines up and moving.

Are you currently pursuing any further education/certifications?

I am really interested in public health and health policy making and may pursue this path in the future.

What’s your go-to breakfast?

A nice cup of black coffee in the morning.

What do you wish everyone knew about PT?

We are not the “torturers” you think we are. We will always motivate you to do more and challenge yourself because we are your “cheerleaders”.

What is the most important personality trait that a PT must have?

In my opinion, patience is a very important trait for any physical therapist to have. Patience to really listen to and empathize with our patient’s issues, as well as having the patience to work with each patient at their own pace.

What do you do to de-stress/unwind?

Playing some tunes on my guitar.

Finish this sentence: On Saturday mornings, you can usually find me…

In a perfect world, I would be up early and laced up, ready for a morning run, or on my way to a good fishing spot.

What is your favorite piece of wellness advice to offer?

Get Moving!!! I know it is easier said than done, but if you pick an activity you like, have a solid plan, start easy and gradually challenge yourself to do more and more, you will be able to achieve anything.

 

Get To Know Your PT: Deanna Marinucci

sf physical therapist deanna

Therapydia SF physical therapist Deanna Marinucci takes some time to talk about her love of group fitness classes, her experience as a physical therapy patient, and the importance of consistency.

“Being a good listener in order to truly understand your patients on both an emotional and physical level.”

When did you know that you wanted to be a physical therapist?

As a former competitive swimmer and soccer player, I had multiple injuries that landed me in physical therapy. I worked with the same therapist from when I was nine years old until I was volunteering for hours to get into PT school. I was inspired to pursue the profession because of their knowledge of the human body and the level of impact they had on people’s lives

What’s your favorite song to get you motivated?

Gimme Shelter by the Rolling Stones

What is the biggest challenge involved in being a PT?

One of the biggest challenges as a PT can be managing your time wisely. When seeing patients full time, we have to manage to finish all of our documentation and still mange to take good care of ourselves.

How do you like to stay active?

I enjoy running, swimming, lifting and yoga. I also love taking group fitness classes so I’ve tried everything from orange theory to CrossFit.

What surprised you the most about the physical therapist profession?

I was amazed by how broad the profession of physical therapy. There are therapists working in hospitals, clinics, schools, etc. with specialties in ortho, pediatrics, geriatrics, neuro. Each subset of PT has different skill sets that make them unique and valuable to their respective setting.

Are you currently pursuing any further education/certifications?

I’m currently working on continuing education to treat pelvic floor dysfunction and women’s health

What’s your go-to breakfast?

Smoothie with protein powder, almond milk and fruit.

What do you wish everyone knew about PT?

That you can now come directly to a physical therapist for an evaluation due to direct access laws. I would love to continue to share with everyone the knowledge that PTs have in diagnosing and treating musculoskeletal conditions.

What is the most important personality trait that a PT must have?

Being a good listener in order to truly understand your patients on both an emotional and physical level. That way we can work together to achieve their goals and improve their quality of life.

What do you do to de-stress/unwind?

Exercise, hang out with friends, listen to music, meditate

Finish this sentence: On Saturday mornings, you can usually find me…

Exploring the bay area. I just moved to San Francisco a few months ago so I’ve been enjoying all the outdoor activities and trying new restaurants.

What is your favorite piece of wellness advice to offer?

Start small and find something that works for you. Find something that you enjoy and find sustainable. Whether that’s enjoying a hike with friends, taking a yoga class or going for a bike ride. Consistency is key.

Get To Know Your PT: Greg Ohanessian

get-to-know-your-pt-greg-ohanessian-sf

Therapydia SF physical therapist Greg Ohanessian takes some time to talk about his love of smoked meats, completing his OMPT residency, and the importance of compassion in the PT profession.

“Everything in moderation. Too much or too little of one thing can be detrimental and this applies to all areas of life!”

When did you know that you wanted to be a physical therapist?

I knew I wanted to be a PT while laying on a treatment table getting my own shoulder therapy back when I was 16 years old. As I gradually felt my shoulder feel better after a football injury, I saw the power of improving mobility and movement to improve life!

What’s your favorite song to get you motivated?

Outside the Fire -Garth Brooks

What is the biggest challenge involved in being a PT?

The biggest challenge as a PT was completing my Orthopedic Manual Physical Therapy Residency through the Ola Grimsby Institute. It included 1 year of deep learning of all anatomy, joint function, pathophysiology, examination procedures and manual therapy techniques. It concluded with a practical test in front of judges. The extra post doctorate year of study has helped me improve my evaluation skills to accurately diagnose musculoskeletal issues and optimally treat my patients.

How do you like to stay active?

I like to take urban hikes with my family, golf and jump on my Peleton!

What surprised you the most about the physical therapist profession?

How under utilized we are as a profession. PT’s unique skill sets to diagnose and provide optimal solutions to musculoskeletal problems are an asset to our communities. I plan to change the publics’ perception of PT and improve access to PT.

Are you currently pursuing any further education/certifications?

I am planning on completing my Titliest Performance Institute certifications to become a level 3 Medical profession for Golfers.

What’s your go-to breakfast?

I start my day early so……Coffee!

What do you wish everyone knew about PT? / What is the biggest misconception you hear from new patients?

Patient’s never know that they can come and see us before there is an injury to keep injuries away.

What is the most important personality trait that a PT must have?

Compassion

What do you do to de-stress/unwind?

I like to BBQ and smoke meats and enjoy a nice glass of wine!

Finish this sentence: On Saturday mornings, you can usually find me…

Pushing strollers around San Francisco or at sporting events.

What is your favorite piece of wellness advice to offer?

A man’s worth is measured with intellectual dexterity and physical vitality.

Click here to learn more about Greg and the other physical therapists at Therapydia SF.

Pilates + Physical Therapy

Pilates Physical Therapy San Francisco

Joseph Pilates, a German medic who trained in boxing and gymnastics, developed Pilates as a form of exercise in the early 20th century. As a child, he suffered from various illnesses and though he had no formal training, was fascinated with the study of human movement and dedicated to improving his physical fitness. Pilates believed that postural dysfunction and inefficient breathing techniques contributed to poor health. Originally called “Contrology”, he considered the method a holistic approach to movement, incorporating mind, body and spirit.

Initially conceived as a sequence of bodyweight exercises performed on a mat, Joseph Pilates invented several pieces of equipment (apparatus) over the years. The Reformer and The Cadillac were both developed from his experimentation with springs attached to hospital beds, and The Chair was inspired by…you guessed it, a living room chair! As its popularity grew, The Pilates Method became mainstream, offered in gyms, studios and taught as an adjunct in physical therapy clinics.

The benefits of Pilates may seem clear. The most commonly mentioned reasons people do Pilates is to improve core strength and stability. Less obvious are two important reasons I suggest Pilates to my patients:

Pilates is a method of exercise that emphasizes on breathing with movement. The ability to coordinate respiration during movement is essential for everyone, yet many are challenged by this seemingly simple act. The muscles of respiration contribute to stabilization, so if respiration is altered, spinal stability will be compromised.

Pilates can be modified for various levels of recovery and fitness. While mat-based Pilates exercises might seem easy, sequences can actually be more challenging than those performed on a Pilates apparatus since participants must control their bodies without any external assistance. The various Pilates apparatuses can be used to increase the challenge of an exercise or to provide assistance to complete a movement. Depending on how the springs on an apparatus are set, there may be an increase in resistance for a focus on strength or a decrease in resistance for improved control. Springs may also be used to provide support, making an exercise more accessible to a healing body.

While its popularity has increased, Pilates as a method of exercise has become less defined over the years. Today, virtually any type of movement performed on a Pilates Reformer or mat can be labeled Pilates and, without experience working with a qualified instructor, you may never know the difference. When your doctor recommends the method, a coworker suggests Pilates because, “it worked for me,” or you choose to do Pilates independently with an online video, you are applying a very broad exercise method to a condition that may require a little more specificity and individualization. In fact, many mat or equipment-based Pilates exercises are flexion-based and are not only inappropriate for some patients, but actually contraindicated (e.g. herniated disc, osteoporosis). Exercises that focus on strengthening the back of the body (posterior chain) may exacerbate other conditions (e.g. stenosis, spondylolisthesis).

As a physical therapist who is Board Certified in Orthopedics, I use my Pilates training to enhance my educational foundation in anatomy, kinesiology, and pathology. In the United States, there is a large discrepancy in the training involved to qualify as a Pilates instructor. Some instructors train with Master Instructors and participate in educational programs that include a basic study of anatomy with observation and practice hours. These programs may also involve an overview of specific injuries and provide information on what types of exercises should be avoided. Other instructors, including those at TherapydiaSF, are licensed physical therapists looking to expand their exercise instruction techniques as a complement to their physical therapy education. On the other end of the spectrum are those who take a weekend class or do some training on their own to teach Pilates.

Modern day Pilates varies dramatically from what its creator originally taught. A savvy, educated consumer should know what to look for when choosing the right class or instructor.

If you’re looking for a form of exercise to support your recovery, start with a physical therapist who is trained in Pilates. Your goal may be to return to work with your Pilates instructor, but a thorough assessment with a medical practitioner (e.g. your physical therapist) will help identify potentially harmful exercises and highlight what you should focus on during your Pilates sessions with your trainer. A successful treatment strategy often includes work with both a physical therapist and a Pilates instructor open to collaborating.

If you are healthy, pain-free, and looking for a challenging workout, you have a variety of options. Many clients continue their work with Pilates instructors who are also physical therapists based on our ability to recognize and address potential injury risks. Group classes might also be a consideration for a more affordable option and for a more social experience. Classes vary in style and are less individualized, so if you are looking for more guidance, we recommend one-on-one training.

Pilates should never replace work with a qualified rehabilitation specialist trained to treat injury. Nor should someone with an injury attempt to use self-guided Pilates exercises to treat or manage their injury. If your physician has recommended Pilates, or you need a specialized program, find a physical therapist with training in Pilates. You will receive a thorough examination that will help the therapist develop a treatment plan and determine if you are appropriate to begin work with a Pilates instructor, or if you should start with Pilates-based physical therapy.

Get to Know Your PT: Laura Sako, TherapydiaSF Physical Therapist

San Francisco Physical Therapy Laura Sako

TherapydiaSF physical therapist Laura Sako takes some time to discuss what she loves about the Bay Area, how she became interested in PT and the one superpower she’d love to have.

What is the best thing about being a physical therapist?

I love having an active job that allows me to meet new people and figure out new puzzles every day.

How did you get interested in physical therapy?

I have a lot of physical therapists in the family so I’ve always been familiar with the profession. It wasn’t until I started volunteering in different settings and interacting with all types of patients that I really began to understand the importance of PT and decided that it was the career I wanted to pursue.

What do you like most about the Bay Area?

The diversity of the neighborhoods. It’s always fun to explore different areas and discover what makes them unique.

What is your favorite place to be active?

The Cascades in Washington. I’m originally from Seattle and that mountain range has a special place in my heart.

What activity in SF is on your bucket list that you’ve still never tried?

Ride a cable car.

What are you currently reading?

The Devil in the White City by Erik Larson

If you could have one superpower, what would it be and why?

The ability to fluently speak every language. My brain is very left-sided!

What is one of your major accomplishments in the last few years?

Drove across the country and passed my Orthopedic Clinical Specialist Exam.

Click here to learn more about Laura and the other physical therapists at TherapydiaSF.

TPSF Holiday Coat Drive: November 13-December 22

Do you have coats in your closet that you no longer wear?

TherapydiaSF is hosting a coat drive for the holidays! Stop by either TherapydiaSF location now through December 22 and donate your gently worn coats to a great cause!

Health experts report that even a 2-degree drop in body temperature results in reduced heart rate, loss of coordination, and confusion. Adults cannot work effectively and children find it difficult to learn. For most, a warm coat solves the problem. But, for the nearly 15% of Americans living in poverty, a warm winter coat is a budget “extra.”

Join the team at TPSF this holiday season to give back to those in need! For every coat you donate, you will receive a raffle ticket for a drawing to be held on December 27th. Three tickets will be drawn for your choice of a physical therapy evaluation, a Pilates session or a RunRx running assessment.

TherapydiaSF-Embarcadero Center: 1 Embarcadero Center, Lobby Level

TherapydiaSF-Market Street: 580 Market Street, Suite 100 (mezzanine level)

Health Insurance 101: Understanding Your Benefits

It’s a new year and, for many people, this means a new insurance policy. While insurance can be confusing, it is important to understand your health insurance benefits as you consider your options for treatment. We’ve put together a handy primer to explain the basic components of an insurance plan, in hopes that it will make life simpler for you!

In-Network vs. Out-of-Network: Providers who are in-network with your insurance company have agreed to accept a lower rate for their services, as determined by the insurance company, in exchange for being affiliated with and promoted as a “preferred provider”. Out-of-network providers determine the value of their services and are not under contract with the insurance company. Most plans have some level of out-of-network reimbursement. Many people think that if a practice is not in-network with their insurance, they can’t seek services at that clinic. In fact, insurance companies may even tell you you have to work with an in-network provider, even if you have out-of-network coverage. This is wrong and misleading. We elaborate more on the difference between in- and out-of-network coverage in this past blog.

Explanation of Benefits (EOB): This is sent by mail or available online after each medical service you receive. Your EOB will include lots of information, but look for the billed amount, allowed amount, any payments made by your insurance company, and the amount you owe, or patient responsibility.

Billed Amount: The amount that your healthcare provider bills to your insurance company.

Allowed Amount: The amount your insurance company deems a service provided to you is worth. This may be equal to the billed amount, though is more often less than the billed amount.

Deductible: This is the amount of money you are required to pay before your insurance benefits kick in. This amount resets annually, typically at the beginning of the year. Occasionally, there are some services where the deductible is waived, but in general you are required to pay the amount of your deductible before insurance pays for anything. Generally, there are separate deductibles for in- and out-of-network providers, though occasionally they are combined.

Coinsurance: Generally, this is the percentage of what you are required to pay per service. This is most often calculated using the allowed amount. For example, 30% coinsurance means that you are required to pay 30% of what your insurance allows for a particular service, while they pay 70%. This shared payment responsibility starts only after you meet your deductible.

Copay: This is a flat-rate amount that you pay each time you visit a provider, regardless of the billed or allowed amounts. This won’t start until you have met your deductible.

Out-of-pocket max: This is the maximum amount of money you will have to pay per year for covered healthcare. Once you reach your out-of-pocket max, insurance should cover 100% of your medical expenses.

Visit limit: This is the maximum number of visits your insurance company will pay. However, this is not a guarantee. Often, an insurance company will state a high number, or even unlimited visits, but will deny payment after review of medical notes if they don’t consider treatment to be justified.

At TherapydiaSF, we are happy to call your insurance on your behalf to determine your specific in- or out-of-network benefits. We also offer discounted cash rates as an alternative, if you are faced with a high-deductible plan, high co-insurance or limited visits. Please let us know how we can help you get started on your path to a healthy 2017!

 

 

Movement Matters

sf_run_assessment

You’ve heard it before, “exercise is good for you.” It probably started with your PE teacher in grade school and now it’s your doctor reminding you at your annual physical exam. It seems that a new study touting the benefits of exercise is reported on the nightly news almost every week. We all know that exercise is good for losing weight and getting stronger, but what you might not realize is that beyond the physical changes you see, by committing to a regular exercise routine, you’ll have a positive impact on your mind, body and soul. So why is it that according to the Centers for Disease Control and Prevention, 25 percent of the U.S. population doesn’t participate in any physical activity?

Mind:
When faced with a busy schedule and too many meetings on your calendar, exercise often takes a backseat. If you’re not sleeping well and wake up exhausted, the last thing you want to do is lace up your running shoes and head out for a sweat session. However, the next time you’re fading midday, consider skipping your visit to the local coffee truck and hit the gym instead.

According to a 2011 study of more that 3000 people, those who get at least 150 minutes of exercise a week sleep significantly better and feel more alert during the day than those who do not.1

In that same year, a study of older adults revealed that regular aerobic exercise increases the volume of the hippocampus, the area of the brain related to memory, and can help improve memory function. While its effect on the mind is continually being studied, findings strongly suggest that exercise promotes improved brain function.2

Body:
You’ve probably known that aerobic exercise is essential for heart health as long as you can remember. Starting an exercise program is often the first piece of advice given to individuals at risk of developing cardiac disease. People who exercise regularly tend to develop less heart disease their sedentary colleagues. If they do develop a form of heart disease, it happens later in life and is generally not as severe.3

Exercise also promotes bone health, an important consideration as we age. While studies are ongoing, one released earlier this year showed moderate intensity aerobic exercise may have a protective effect on bone and cartilage by regulating elements in the body involved in increasing our bone mass density.4

A strong heart and strong bones are important, but exercise can help the body in other ways. Emerging research suggests that moderate amounts of exercise may have a positive effect on chronic pain by changing an individual’s perception of and response to their pain.5 Movement continues to be the most conservative, most inexpensive, and likely the most effective treatment for lower back pain, a condition that affects 80% of us during our lives.

Soul:
Have you ever started a workout in a bad mood and ended it feeling even worse? Not likely. Do you alleviate stress with a tough session? You might be on to something. There is a strong link between between exercise and mood. In general, active people are less depressed than sedentary people. A 2007 study concluded that exercise was generally comparable to antidepressants for patients with major depressive disorder.6 A hot topic of research in the mental health field, scientists are extremely interested in learning how to prescribe exercise as treatment for a variety of conditions including stress, anxiety, and depression.

The more digitally connected we are, the less real contact we tend to have with friends and family. There’s an app for everything, but not one that promotes in-person interaction with our true social circles. Exercise has a positive effect on our relationships and can even lead to developing new friendships. Finding a common exercise interest increases motivation, fosters healthy competition and can create strong social bonds with friends and family.

The benefits of exercise are vast and the scientific support of movement continues to grow. Who wouldn’t want to look better, feel better and be better? If you’re a regular exerciser, keep it up! The changes you’re making are huge. If exercise hasn’t been your thing, find something you enjoy, commit to your health and get moving. Your mind, body and soul will thank you.

  1. Loprinzi, Paul and Bradley Cardinal. “Association between objectively-measured physical activity and sleep, NHANES 2005–2006.” Mental Health and Physical Activity2, (2011) 65–69.
  2. Ericksona, KI, et al. “Exercise training increases size of hippocampus and improves memory.” PNAS 108.7, (2011) 3017-3022.
  3. Myers, J. “Exercise and Cardiovascular Health.” Circulation.107(2003) e2-e5
  4. Alghadir, JH, et al. “Correlation between bone mineral density and serum trace elements in response to supervised aerobic training in older adults.” Clin Interv Aging.11 (2016) 265-73.
  5. Jones, MD, et al. “Aerobic training increases pain tolerance in healthy individuals.” Med Sci Sports Exerc8(2014) 1640-7.
  6. Blumenthal, JA, et al. “Exercise and pharmacotherapy in the treatment of major depressive disorder.” Psychosom Med. 7 (2007) 587-96.

 

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