Rick shares: Research on Massage for Carpal Tunnel Syndrome


Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is a condition characterized by tingling, numbness and pain in the hand and fingers (particularly the thumb, index, middle and ring fingers). These symptoms are often the result of median nerve irritation in the wrist or forearm.

BLAUSEN.COM (2014). “MEDICAL GALLERY OF BLAUSEN MEDICAL 2014”. WIKIJOURNAL OF MEDICINE 1 (2). – CC BY 3.0.

Why Give Massage Therapy A Try?

Massage therapy as a therapeutic intervention is being embraced by the medical community, it is simple to carry out, economical, and has very few side effects. One area that is being explored is the use of massage therapy for patients who suffer from carpal tunnel syndrome.

Randomized clinical trials have demonstrated that for some patients who suffer from carpal tunnel syndrome there is no significant differences in pain and functional outcomes at six and twelve months when surgical and conservative care are tested (Fernández-de-Las Peñas et al. 2017).

Why Does Massage Therapy Work?

The responses to massage therapy are complex and multifactorial – physiological and psychological factors interplay in a complex manner. Research has looked at both peripheral and central responses elicited by massage therapy treatments.

Pain Management
Massage has a modulatory affect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from carpal tunnel syndrome.

Peripheral Response
The median nerve passes through many structures and it may be exposed to mechanical irritation at many different points (Filius et al. 2017). Prolonged irritation may result in a reduction of intraneural blood flow. In turn, local hypoxia of a peripheral nerve leads to a drop in tissue pH that triggers the release of inflammatory mediators, known as “inflammatory soup”, this noxious substance can disrupt the normal function of nerves. Massage therapy may diminish intraneural edema and/or pressure by mobilizing the median nerve as well as associated vascular structures (Boudier-Revéret et al. 2017).

Carpal tunnel specific work may also involve specific soft tissue treatment to optimize the ability of mechanical interfaces to glide relative relative to the median nerve. Ongoing tissue hypoxia or inflammatory responses lead to molecular signaling that promote the development of fibrosis, this may contribute to further peripheral nerve dysfunction (Fisher et al. 2015). The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of fibrosis and TGF-β1 (Bove et al. 2016).

Infraspinatus Test in Carpal Tunnel Syndrome

 The infraspinatus provocation test ( Meder et al. 2017 ).

THE INFRASPINATUS PROVOCATION TEST (MEDER ET AL. 2017).

The etiology of myofascial triggerpoints are still not well understood, but that does not deny the existence of the clinical phenomenon.

A contemporary view of ‘myofascial trigger-points’ is presented by Shah, this categorizes ‘myofascial trigger-points’ by the a number of measurable characteristics: local and remote inflammation, local acidic milieu, local sensitization, local regions of hypoxia, local muscle stiffness (Shah et al. 2015).

Studies have demonstrated that assessing and treating the infraspinatus muscle may be an effective treatment option for a sub-group of patients with suffer from symptoms that present similarly to carpal tunnel syndrome (Meder et al. 2017).

Structures To Be Aware Of When Treating Carpal Tunnel Syndrome

Systematic reviews have also shown that manual therapy combined with multimodal care can improve symptoms, decrease disability and improve function for patients who suffer from carpal tunnel syndrome (Huisstede et al. 2017). Additionally, a recent randomized controlled trial in the journal Brain found that acupuncture improved the outcomes for carpal tunnel syndrome by remapping the brain (Maeda et al. 2017).

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from plantar heel pain may include neurovascular structures and investing fascia of:
• scalene muscles
• costo-clavicle space
• pectoralis minor
• biceps brachii muscle
• bicipital aponeurosis
• pronator teres
• transverse carpal ligament
• anterior interosseous membrane
• palmar aponeurosis
• infraspinatus
• lumbricals

Improving Cognitive Function in Older Adults

The prevalence of Alzheimer’s and various forms of dementia are on the rise in western society and scientists and doctors alike are looking for ways to prevent and combat these horrible diseases . Luckily, recent studies have found promising strategies to reduce the rate of cognitive decline as we age. For many years research has shown that regular exercise leads to improved physiological and cognitive function. As the general population becomes more sedentary at home and in the work place, the role of exercise for improved health has become increasingly important.

The current hypothesis to explain the positive cognitive effect of exercise is that physical activity induces neural and vascular adaptation that promotes neurogenesis. In other words, maintaining exercise in your daily life will help increase the brains ability to produce new neurons. Physical activity will also decrease systemic inflammation and reduce cellular damage caused by oxidative free radical. As a result, older adults who engage in moderate amounts of physical activity maintain a higher level of cognitive functioning

 

The results of this meta-analysis demonstrated that both aerobic and resistance training exercise were beneficial in improving cognitive outcomes in people over the age of 50. It is recommended that training sessions should be 45-60 minutes in lengths and performed at a moderate to vigorous intensity. These results are not surprising and will hopefully provide aging adults with a starting point in preventing age-related dementia.

For some, it may be a challenge to create a workout plan that suits their specific physical capacity. I recommend seeing a health care practitioner with proper training in therapeutic exercise and rehabilitation to at least get you started! Taking on a training program can be overwhelming for beginners and having a helping hand and some extra motivation will go along way. Many chiropractors will be able to get you started and guide you on your journey to healthier and more rewarding life!

Northey JM, Cherbuin N, Pumpa KL, Smee DJ, Rattray B. Exercise interventions for cognitive function in adults older than 50: a systematic review with meta-analysis. Br J Sports Med. 2017 Mar 30:bjsports-2016.

Dr. Laura: Is Fasting Safe?

Fasting is part of the human existence for thousands of years. As you will learn in this article, not only is it safe, it has numerous health benefits.

Image result for empty plate

What is fasting?

There are many ways people approach a fast. It is simply a period of not eating. It may be done weekly until you reach your health targets, seasonally, or a couple times a year. Water intake is necessary during periods of fasts, as our bodies can do without calories, but not without water. Many choose to fast overnight (most common) from dinner to breakfast, or 7pm to 7am – a 12 hour fast. Then “break-fast” is just that, it breaks the fast. Recently it has gained more popularity and there are different lengths of fasts.

  • intermittent fast, lasting 12-20 hours
  • 24 hour fasts
  • 36 hour fasts
  • extended fasts

Sometimes on the intermittent fasts, people will have a coffee or tea and water while they are not eating. If you truly wish to detoxify, caffeine free is the way to go. So herbs in water or  lemon certainly is less stimulating. For others they choose to incorporate bone broth, which really has proteins and fats in it, but can be suitable for introductory fasting and digestive rest.

Are there benefits to fasting?

  • weight loss
  • reset insulin sensitivity
  • digestive rest
  • more powerful than low carb, ketogenic diets alone
  • protects from illness and maintains wellness
  • provides spiritual cleansing or purification
  • no cooking, cleaning, or grocery shopping!
  • mental clarity
  • overcome stubborn weight plateaus

Will I get hungry?

Hunger may set in, same as if you were at work and didn’t get a break and had to wait to eat, same experience – you push it through till it’s time to eat. But you should never feel nauseated, ill, dizzy or faint. If you do really feel the intense need to eat, it’s easy – you eat. Then you could try the fasting again next week.

Fasting will switch you body to burn fat instead of carbohydrates. If your body is primed to burn carbs, you will need to get over the initial bout of strong carb cravings before the fat burning kicks in.

What do I eat when I am not fasting?

What you eat when you are not fasting depends on the reasons for your fast. If you are trying to loose weight or reset your insulin sensitivity, then a ketogenic diet may be best. For those on a digestive fast, re-introduce with easy to digest and simple combinations of foods. A spiritual fast? Then you likely just go back to your regular way of healthy eating. Regardless, you do no want to eat to make up for the time you fasted: that’s counterproductive. If you are doing one or two 24 hours fasts per week (having a couple one meal a day kind of routine), then when you are eating regular on the other days, eat the most healthy vibrant life-filled food that you can. Avoid things that are packaged or processed to get the most nutrition you can on the days you eat.

When is fasting not safe?

Fasting is not safe for the following people:

  • children aged 18 or under
  • pregnancy
  • breastfeeding
  • thin, weak or feeble
  • nutritionally deficit

Fasting needs to be medically monitored for the following people:

  • those with gout
  • those taking medications
  • if you have type 1 or 2 diabetes
  • those with gastro reflux disease

For questions or advice on what kind or whether fasting is right for you, book an appointment to review with Dr. Laura M. Brown, ND. (519) 826-7973.

References:

Fun Jason. 2016. The complete guide to fasting. Victory Belt Publishing. Las Vegas.

2 for 1 Orthotic Insoles Promotion

It’s That Time Of Year Again, as we’re heading into Fall, and it may be time to Check In for New Or Renewed Custom Orthotic Insoles, with Dr. Phil’s 2 Pair for the price of one promotion.

Are there are some signs or clues that I might need custom foot 

timthumb

Orthotic Insoles?

  • Walking with a limp or your toes pointed in our out.
  • If your posture is poor or altered.  Check to see if your head, shoulders and hip heights are equal heights (normal) or if one side higher than the other (abnormal).  Have someone check your posture sideways.  Your ear should be in line with your shoulder and hip.  Does your head stoop or jut forward with your shoulders rolling in?  This “forward head posture” is abnormal and can cause a variety of health problems.  Abnormal posture can be linked to a foot problem throwing your posture out of balance.
  • Obvious shoe wear, such as excessive wear points or uneven wearing on one shoe or between both feet. Outside heel area wear is often a positive sign for over pronation (flat feet).
  • Knee or hip pain when walking or exercising can suggest a misalignment or instability in the feet.
  • Symptoms of faulty foot mechanics could include localized:
    • foot pain
    • bunions
    • hammer toes
    • arch, heel pain
    • leg, knee, hip or back pain
    • neck pain

How do I know if I need foot orthotics?

During your initial evaluation or during a re-evaluation, Dr. Phil will watch how you walk (gait analysis) and will also do a digital scan (using a 3-D Laser Computer Aided Design/CAD System) to assess how you are weight-bearing on the bottom of your feet, and he will do a postural evaluation and will visually inspect if you have overly high arches or dropped arches (flat feet).

image2 foot mechanics

I have good shoes.  Why do I need foot orthotics?

A high quality supportive shoe is indeed the most important element for your feet.  However, the insole is not custom-made for your foot.  By inserting a custom-made foot orthotic into a good quality shoe, you are ensuring that you give your feet optimal alignment, balance and stability.  Most shoes people wear have an existing insole that easily slips out and the orthotic can slip into the shoe to replace the original insole.

Will I have to buy new shoes?

It Depends!  The foot orthotics are not a thick, hard plastic, or rigid design.  They are slightly thicker than your existing insole, but have good cushion and enough rigidity to correct most foot imbalances.  Your custom orthotic insoles are most effective when used in shoes with good construction, fit, and condition.  Your orthotics are also a guide in assuring new shoes fit well.  If a shoe can’t accommodate a stabilizer which has been custom made for your foot, then that shoe is not the proper size for you.

I have different types of shoes.  Can I use them in all of my shoes?

If your shoes are a similar style you just move you foot orthotic from one shoe to the next.  There are different orthotics for different types of shoes.  For example, men’s and women’s lace up shoes that have a wide forefoot usually need a full-length orthotic whereas a slip on shoe may require an orthotic that is shorter in length.  There is a variety of foot orthotics for a variety of shoes.  To start, we usually recommend buying a pair of foot orthotics for the type of shoe you wear most, and with Dr. Phil’s 2 for 1 promotion, then have a second pair for either a different type of footwear or to have more than one pair of orthotics for similar footwear.  This saves you from having to constantly switch the orthotics from one pair to another.

I wear sandals in the summer.  Can I wear my regular shoe orthotics in my sandals?

No.  However, Dr. Phil does prescribe and dispense very comfortable Sandal orthotics insoles, as well as sandals.

What kinds of foot orthotics are there?

There are a variety of foot orthotics for a variety of shoes:

  • Men’s shoes
  • Women’s shoes and boots
  • Workboots
  • Children’s shoes (ages 5 to 12)
  • Golf shoes
  • Sandals

See the full line of Custom Orthotic Insole Styles: http://www.atlasorthoticlab.com/orthotics/ 

How do I Set Up An Assessment with Dr. Phil?

Get Help Now with Dr. Phil McAllister @ Forward Health or contact the clinic directly by phone at 519-826-7973, or by e-mail: info@forwardhealth.ca

An assessment with Dr. Phil will then be booked for approximately 30 minutes, and during that time he can help order the right kind of foot orthotic for you.

  • The Process

Custom design for foot orthotic insoles are through a 3-D Laser CAD imaging process.

Once the examination is completed, and you decide to go ahead with the prescription recommended by Dr. Phil, then,

  1. The casting kit or digital scan is sent to the Atlas Orthotic Lab (http://atlasorthoticlab.com/).
  2. Skilled technicians build your custom-made foot orthotics using 16 precise measurements based on their analysis of your feet. Your lifestyle, age, weight and activity level are all considered when the custom-made foot orthotics are fabricated.
  3. The foot orthotics are then shipped back to Dr. Phil at Forward Health. Your Orthotic insoles are usually back to the clinic within 1 week.
  4. Instructions will be given on how to wear and care for them on the fitting which is set up by the clinic once the orthotic insoles arrive from the lab.

How much do custom-made foot orthotics cost?

The price for the prescription and provision of the 2 for 1 promotion for custom orthotic insoles with Dr. Phil is $500 in total.  If you only need one pair and don’t need to take advantage of the 2 for 1 promotion, then the cost is $400.00 in total.  There is a $50.00 examination fee for the initial visit and it is built into the total cost if you decide to purchase the custom orthotic insoles.

Most health insurance plans cover some or all of the cost of custom-made foot orthotics.  Check your plan specifically for coverage amounts and who is payable regarding types of practitioners.  Payment is required prior to sending your order to Atlas labs as they charge us as soon they get the order.  If you have insurance make sure you know what they require so you can get reimbursed.  They will require a receipt from us for sure.  Sometimes a prescription letter from us or a note from your medical doctor is required.  Sometimes they require a detailed lab report, so Dr. Phil will always do a full detailed report with the manufacturing process etc.  That way you have all the specific necessities for your coverage.

How long do custom foot orthotics last?

Approximately 2-3 years with everyday usage, and then they should be replaced. Many insurance companies re-new custom orthotic insole prescriptions every 2 years.

Looking forward to empowering you to continue to live long & strong, and stay in the Game For Life!

Dr. Phil McAllister @ Forward Health

ACRB, CTPI, DC. ABFP, CSCS, CCSP

Rick’s Chicken Recipe

Love fried chicken but don’t want all the fat? Try this recipe for all the flavour of your favorite food without deep frying!

Ingredients:

4 large skinless boneless chicken breasts or 6 chicken thighs
1 tsp garlic powder
1 tsp poultry seasoning
1 tbsp dill
1 tsp paprika
1 tsp salt
1 tsp pepper
3 tbsp parmesan cheese
1 cup fresh bread crumbs

Note: Spices can be altered to suit your own taste.

Instructions:

  • Preheat oven to 400 degrees
  • Line baking sheet with parchment paper
  • Combine bread crumbs, cheese and spices in a bowl
  • Brush chicken with olive oil
  • Dip chicken in bread crumbs to cover
  • Lay breaded chicken on parchment lined baking sheet
  • Put breaded chicken in oven and bake 30 to 40 minutes until lightly browned

Dr. Laura: Ear Wax Facts

Earwax, (medically known as cerumen auris) is a protective normal secretion from a skin gland in the external ear canal. Some people make more earwax than others. Certain habits or careers may put an individual more at risk for earwax impaction.

 

Do you wear earphones, earplugs hearing aids or use Q-tips?

Do you have dizziness,  ear pain, itchy ears, or hearing loss?

If so, you may have earwax impaction.

Image result for ear wax impaction
picture from hearingaiddoctors.com

What is earwax?

  • 60% skin cells that have shed from the area
  • 12–20% saturated and unsaturated long-chain fatty acids
  • 6–9% cholesterol

What is the purpose of earwax?

  • Lubricates the external auditory canal
  • Protects particles from reaching and damaging the eardrum
    • Traps dust, small particles and insects
  • Provides antimicrobial protection (acidity, fatty acid and lysosome)
    • Protection bacteria and fungal infections

What is earwax impaction?

Image result for ear wax impaction

  • Earwax impaction is one of the most common ear problems
  • When earwax accumulates in the canal and, on otoscopic inspection, blocks the view of the external canal or tympanic membrane
  • When the use of ears swabs or other devices in effort to clear the ear push the earwax deeper into the ear
  • Chronic use of hearing aids, earplugs, headphones, can also push the earwax further into the ear and prevent the natural migration outward
  • Excessive earwax production can also worsen with anxiety, fear and stress, and aging
picture from journals.sagepub.com

What are the symptoms of earwax impaction?

  • Irritation of the ear
  • Sensation of an ear blockage
  • Reduce sense of hearing
  • Earache
  • Noise in the ear or head
  • Dizziness

How to clear out earwax?

Image result for tympanic membrane
healthy ear canal and tympanic membrane
  • DO NOT use Q-tips! They tend to push the ear wax deeper into the canal.
  • Naturally, the earwax dries up and there is a migration of skin cells that helps port the dried up was out of the external canal, much like a conveyor belt
  • Assisted action of clearing out by the action of chewing and talking
  • There are products that may soften the wax however this should only be done under medical supervision.
  • It is best to have the ears looked at with an otoscope to see if there is indeed a build up and if the tympanic membrane is intact
  • Candling is not recommended as it has not shown to be overly effective and can often lead to burns, wax left behind in the ear, irritation of the external ear canal and occasional temporary hearing loss.
  • Ear irrigation is a safe and effective way to clear out earwax, so long as the tympanic membrane is intact.
  • Professional irrigation can be more effective than self-irrigation as it include the visualization of the health of the external canal and tympanic membrane before and after treatment.

Laura M. Brown, ND

provides a basic ear inspection and ear irrigation service

within a 15 minute appointment. Call (519) 826-7973

Image result for ear wax irrigationpicture from earwax treatment.com

References

Adegbiji WA, Alabi BS, Olajuyin OA, Nwawolo CC. Earwax Impaction: Symptoms, Predisposing Factors and Perception among Nigerians. Journal of Family Medicine and Primary Care. 2014;3(4):379-382. doi:10.4103/2249-4863.148116.

Daniel F. McCarter MD, A. Ursulla Courtney, MD, and Susan M. Pollart, MD, University of Virginia Health System, Charlottesville, Virginia. Am Fam Physician. 2007 May 15;75(10):1523-1528.

Rafferty J, Tsikoudas A, Davis BC. Ear candling: Should general practitioners recommend it? Canadian Family Physician. 2007;53(12):2121-2122.

 

Rick shares: Why athletes should include massage in their fitness regimen

LifeBridge Health
July 23, 2018

By LifeBridge Health

Why athletes should include massage in their fitness regimen
The overexertion of muscles through rigorous physical training and exercise can affect athletes’ performance and increase their risk for injury. In between those strenuous workouts, the body could use some pampering.

Regular massage supports the relaxation and recovery process after workouts, helping to prevent injuries; reduce swelling, muscle stiffness and fatigue; and achieve peak performance. And there are numerous other potential benefits that are conducive to your overall health and well-being. Massage therapy helps to improve muscle flexibility (which helps prevent injuries like muscle pulls and tears) and shorten recovery time as well as relieve muscle tension and pain, a remedy for common issues like delayed-onset muscle soreness. But massage can benefit more than muscles. Tammy Taylor, massage/bodywork team leader and a certified neuromuscular therapist at LifeBridge Health & Fitness, says some research suggests that massage may also help:

  • Lower anxiety Increase range of motion
  • Improve your mood
  • Lower blood pressure
  • Enhance blood flow and alertness

Massage is good for the body either before, during or after athletic events. Sports massage incorporates Swedish (for improved circulation) and deep tissue techniques, among others. Athletes, or anyone who does strenuous exercises on a regular basis, should speak with a massage therapist about specific needs and concerns in order to determine how often massages are necessary and which techniques are most appropriate.

“Your injury or needs will determine the focus of the therapy,” Taylor says. “Often times, an athlete has a specific area in which they are experiencing pain, limited range of motion, etc. That area, in addition to the supporting muscles and connective tissue, is addressed.”

Taylor adds: “A full body massage at another time, maybe within a week or two, is also very helpful for the whole body compensates for an injury, and an injury heals more quickly when the rest of the body is free of limitations.”

Dr. Laura: Long Term Effects of Cortisol and Stress

Cortisol is released in a daily rhythm, but also in response to stress. Ever wonder what are the long term effects of cortisol (stress) in the body?

picture from  philosophytalk.org

Long term danger can be perceived in the form of anything that takes away our freedom, feeling unloved, feelings of insecurity, projecting into the future something that is not true, as if it were and  fear-based memories for future survival so as to avoid any repeat of traumatic events.

Cortisol is not all bad, it has some daily and life-saving functions. The problems lies when the body gets stuck in fear gear, cannot return to its natural state of homeostasis and subsequently has difficult with rest and digestion.

Normal Cortisol Function

Cortisol hormone produced by the adrenal glands. It is released twice a day with blood levels peaking in the morning, and rising slightly again in mid afternoon.

Throughout the day, cortisol:

  • Helps provide energy; maintains blood glucose
  • Suppresses nonvital organ systems to provide energy to the brain, nerves and muscles
  • Is a potent anti-inflammatory hormone
  • Prevents widespread tissue and nerve damage associated with inflammation

Short Term Stress Response

In response to a moment of physical or emotional shock or trauma, the body releases three main chemicals: epinephrine, norepinephrine and cortisol. In the short term, these chemicals trigger a series of events in the body to promote survival including anti-inflammatory actions and activation of energy to flee from the danger. Short term response has a clear purpose to better outcome (safety, life).

Once the epinephrine, norepinephrine and cortisol are released into the blood flow,

  • heart rate increases
  • blood pressure increases
  • respiration rate increases
  • arteries vasoconstrictor & release sweat.
  • pupils dilate
  • Pro inflammatory response so as to destroy antigens, pathogens, or foreign invaders; adrenoreceptor antagonists have been shown to inhibit stress-induced inflammation and cytokine production by blocking the proinflammatory effects of norepinephrine.

Long Term Cortisol Danger

Body’s release

When the brain feels you are in danger on an ongoing basis, cortisol release goes into overdrive. This can be things that threaten our survival like financial concerns, relationship problems, too many commitments, feelings of bitterness towards others, anger, resentment, being unhappy with yourself, lack of faith, hope, love, fear of loosing something you treasure… the list can go on.

Basically the body gets stuck in some type of survival mode. It is then difficult to re-establish to its natural balance.

Medications

Long term medications that end on “-sone” are often producing similar effects to cortisol in the body. These are drugs that suppress the immune system like prednisone, hydrocortisone.

Cortisone type drugs are used to treat pain, allergic disorders, skin conditions, ulcerative colitis, arthritis, lupus, psoriasis, or breathing disorders.

Be sure to also be aware of information on cortisone drug side effects. 

  • Osteoporosis
  • Muscle wasting
  • Hypertension
  • Hyperglycemia
  • Hyper irritability
  • Depression
  • Weakness
  • Vascular fragility including easy bruising
  • Striae or redish stripes over the lower abdomen (thinning of the skin structures)
  • Suppressed immune system, make it easier to get infections
  • Central obesity

If you feel like you are “always on” , have difficulty digesting food or feel “tired and wired”, chances are you are running the meter up on cortisol. As you can see the long term effects are not favourable for good health.

Have Hope

Don’t give up hope, however. The first step is to recognize what is stressing you out. This is more than relationships, it can be pain, inflammation, poor diet, lack of sleep, poor coping mechanisms or genetic wrinkles.

Resolution doesn’t happen overnight but can be improved on a steady course of treatment over time.  Treatment will look at things like sleep hygiene, a healthy diet, the right amount and type of exercise,  and new perspectives on managing yourself in relationships with yourself and others.

The Last “Peace”

Need more peace in your life?  Join me at Goodness Me! on Sept 19th in a presentation on Anxiety Antidotes.

 

References:

Constanzo LS. 2011. BRS Physiology Fifth Edition. Walters Kluwer|Lippincott Williams & Wilkins. Philadelphia.

Hannibal KE, Bishop MD. Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. Physical Therapy. 2014;94(12):1816-1825. doi:10.2522/ptj.20130597.

Wright H. 2009. A More Excellent Way. Whitaker House. Pennsylvania.