In response to your questions.....Posted by Dr. Sandell on 6/20/04 at 14:15 (153550)
Good afternoon friends! I hope that you have had the opportunity to become familiar with the soft tissues response to injury. Before I begin to discuss the pathogenesis of plantar fasciitis, I want to make it clear that this is for information purposes only and is not intended for diagnosis, self treatment, or to replace your current medical therapy. I am only offering you scientific information and my humble opinion. Additionally, I will try to put things into layman's terms so that it will be easier to understand and please forgive any details that may be missed. I will also try to generalize, using the 'most common scenarios to address the majority of you. I do understand that everyone's situation is unique and that can only be properly addressed with a thorough history and examination. The material presented goes much farther into depth and cannot be fully addressed, especially on my only day off! With that being said, I would like to mention that I am more than happy to take this opportunity to offer you insight and help answer some questions that you may have, if only to help you seek an alternative treatment for your condition. I specialize in the treatment of chronic pain, and so I understand the frustrations and despair that you experience. I truly empathize with patients such as yourself and I really wish you all the best of luck.
Overuse injuries frequently occur when an athlete changes exercise patterns or rapidly increases the amount or intensity of exercise. Without sufficient time for recovery, repetitive micro-trauma leads to inflammation and local tissue damage in the form of cellular and extracellular degeneration. Such degeneration can lead to chronic pain or sudden injury. An increase in injury risk with lighter loading is explicable in terms of decreased tensile strength of over-used tissues. Plantar fasciitis occurs when there are small tears in the plantar fascia due to repetitive micro-trauma that cause the ligament to become inflamed. The tears in the plantar fascia initiate an orderly sequence of events i.e. inflammatory phase; fibroblastic / proliferative phase; and remodeling / maturation phase. Below is a brief overview:
Inflammation results from changes in the blood flow caused by clotting and the release of certain substances from the injured tissue. Swelling is a necessary part of this phase, but it must not be too great. The inflammatory phase is a relatively uncontrolled process and the body tends to produce a greater response than necessary, and that is why it is recommended to use ice, compression, nsaids (anti-inflammatory drugs) to control this process. However it is necessary for proper healing to begin. All contamination must be removed, through the process of phagocytosis, in which cells known as phagocytes consume particles of debris around the site of injury. In addition, a new blood supply must be provided through neovascularization, the formation of new blood vessels.
The fibroblastic / proliferative phase of healing is the rebuilding phase and this is when scar tissue is layed down. The fibroblastic proliferation is responsible for the repair and regeneration of collagen. The scar tissue produced initially is 'immature as the bonds holding them together are weak and easily disrupted.
The remodeling / maturation phase of healing is when collagen maturation and final scar tissue formation begins. At this point, the soft tissue injury needs to be strengthened and the normal function returned. The balance of newly formed scar tissue with the destruction of the old, assists in the final physical characteristics of the scar, as do certain soft tissue manipulative procedures performed on the scar. The collagen that has been deposited undergoes reorganization to a stronger type of collagen and the tissue usually becomes somewhat more elastic. The Davis Law states that soft tissues heal along the lines in which they are stressed. Immobilization prevents the formation of strong scar tissue by avoiding the strains leading to proper orientation of the fibrous tissue.
The above response to a soft tissue injury has been accepted as the process at which all tissues heal. However, when an injury is due to a non-traumatic, chronic overuse causation, the typical inflammatory process does not occur. Instead a non-inflammatory process occurs in which there is a degradation of the tissue. This tissue becomes less elastic, weaker, and more prone toward exacerbations with use or stress resulting in chronic pain and disability. How many of you have tried walking or running again because you were asymptomatic, only to experience an exacerbation of your foot pain later?
Healthy tissues fibers are organized with the fibers orientated parallel to each other and are extensible; this gives it function and strength. Scar tissue is fibrotic, dense, irregular, inflexible and weak. As scar tissue matures, it contracts and becomes even less flexible. Scar tissue is necessary however to repair the injured tissues in our body and is not considered unhealthy. When the scar tissue has healed properly, with function and strength, I use the term 'functional scar . I use the term 'pathologic scar when the tissue has not healed properly and is a cause for the exacerbations with use or stress resulting in chronic pain and disability. I believe that these are terms (functional / pathologic) that I only use, however the descriptions of the types of scar are accurate.
The main theory as to why transverse friction massage (cross-fiber massage, deep transverse friction massage) works has been based on its effect on scar tissue. TFM is particularly effective at breaking down excessive scar tissue lesions or adhesions present and in the process of formation. Reduction in these adhesions helps to restore the broadening of tissue required for normal movement. It also induces traumatic hyperemia, or increased local blood supply to the injured tissue. Increased blood supply reduces pain to an injury and facilitates healing. Gentle transverse friction, applied in the early inflammatory phase enhances the mobilization of tissue fluid and therefore increases the rate of healing. The reason why I wanted to make the above a point, was because it is my opinion that this type of procedure should only be performed by an experienced practitioner due to the possible adverse side affects, early stages of an injury require less pressure and treatment time (I believe that the power that can do good, can also do harm). Recent studies using light microscopy, electron microscopy and immunoelectron microscopy have shown that after friction massage there is fibroblastic proliferation and realignment of collagen fibers. The micro-injury causes microvascular trauma and capillary hemorrhage, resulting in a localized inflammatory response which serves as the stimulus for the body's healing cascade and immune/reparative system. This means that the practitioner can influence the orientation at which the new scar tissue is laid down and facilitate healing. It is important to note that TFM does not get rid of the scar tissue it only influences the formation of a 'functional scar . TFM also stimulates fibroblastic proliferation (responsible for the repair and regeneration of collagen). Studies have demonstrated that the fibroblastic proliferation was directly dependent upon the magnitude of the applied pressure by the practitioner. I would also like to mention that this type of procedure is very specific. The scar tissue formed on your plantar fascia does not run the length of the tissue. I am sure that most of you have found 'hard spots on your foot (most commonly by the heel, but not always) and this is commonly the scar tissue. If the practitioner working on scar tissue on your feet is off by ¼ of an inch, they might as well be working on your shoulder. This is yet another reason that this procedure should be done by an experienced practitioner. So in layman's terms, TFM will affect the soft tissue by:
1. Break up adhesions and cross-linkages
2. Realign the fibers
3. Repair and regenerate the fibers
4. Restore extensibility to the tissue
So what about the contractures and shortening that occurs with chronic 'pathologic scar tissue ?
I utilize a different type of soft tissue mobilization technique to address the above phenomenon that occurs with chronic scar tissue. I use a technique familiar to Graston or myofascial release. Well which one is it? All of you should know that in our profession someone will use a technique that has been around for a century and slightly modify it. By either by performing that technique with a tool or a slightly different technique and call it by another name, claiming a new innovation that will cure everyone of their plantar fasciitis! I even have a hard time keeping up with all of the different names of techniques out there, but I can understand what they are trying to accomplish and take it at face value. I am very critical as to 'new treatment and use only the scientific research to dictate what type of treatment I perform. Anyways, these techniques can be utilized to lengthen the contracted tissue.
So what about making the scar tissue stronger?
We have already made the scar tissue stronger by restoring the function and extensibility of the tissue but we are missing one final aspect. During the maturation phase, scar tissue is re-shaped and strengthened by the internal and external mechanical stress applied and is the main stimulus for remodeling weak scar tissue with fibers oriented in all directions and through several planes into linearly re-arranged bundles. At the heart of functional rehabilitation are Davis' Law and Wolf's Laws, which state that soft tissue and bone heal along the lines in which they are stressed. What does this mean? It simply means that tissues will adapt to the forces placed upon them and remodel themselves to become stronger in relation to those imposed forces. Functional rehabilitation includes muscle stretching, gait training, muscle strengthening and neuromuscular re-coordination (nerves, muscles and joints working together in synchrony). Rehabilitation also involves exercise movements to regain joint proprioception. Impaired joint 'position sense' is overlooked in many rehabilitation programs and may be a major risk factor for recurrent injuries after the muscles and ligaments have been restored. Restoring proprioception after injury allows the body to maintain stability and orientation during static and dynamic activities. The development of a rehabilitation program needs to be a methodical and should be supervised by an experienced practitioner. Patient goals must be addressed early so that a progressive rehabilitation program can be developed. Does this mean walking or even running? Absolutely! I cannot say with absolute certainty that this is a possibility for every patient. There are far too many variables that can affect the patients' prognosis and an experienced practitioner should be able to recognize such variables.
Again, the depth as to which I can go into this material is far too extensive and I have not even covered every aspect. It has to be understood that what works for one patient, may not work for another. Again, working with chronic pain patients I understand this very clearly. What does it mean to specialize treating this patient population? It means that I manage only the most difficult cases. I see the patients where other treatment protocols have failed or come up short. This means that I am forced to 'think outside of the box . I wipe the slate clean with every patient and develop a very individualized treatment program, meaning that I do not use protocols to treat the patient for their condition. I do not discredit the other practitioners that these patients have sought treatment from because I do not see the patients in which they have resolved their condition. I think that it is important as all health care practitioners to recognize that we do not have all of the answers and there are other treatment options available to the patients. After all we all have the same goal, which is to provide the patient with a solution to their problem. I wish you all the best of luck my friends and thank you for your time.
Re: In response to your questions.....Dorothy on 6/20/04 at 15:49 (153553)
Thank YOU, Dr. Sandell! It is very generous and thoughtful of you to share this information. I have done a quick reading of it and will go back and re-read it more slowly and carefully. I think that, as much as I am learning from your information that makes so much sense, I appreciate your outlook and attitude. Thank you again.
A few quick questions come to mind:
1. Specifically about seeing you: what can a patient who does not live near your practice realistically expect in terms of time needed (staying at a motel, for example) and any follow-up/maintenance?
2. For those of us here who are slightly, moderately, or greatly overweight, does this affect your ability to 'find' the problem areas, the patient's benefit from the treatments,for you to give the treatments?
3. What kind, if any, previously done test results (x-rays, mri, anything else) do you require that a patient provide you in advance?
4. Do you use - and get good results - these techniques on Achilles tendon problems, sciatica and any other back problems??
5. Does this treatment usually require regular/frequent/occasional doing again? Or never?
6. Do you do any patient teaching or provide any teaching of at-home/self-care that can be done by patient/family at home to maintain the benefit gained from treatment?
Ok, I've taken more than enough of your and everyone's time. I hope these are questions that many others here would want asked as well. Thank you again so very much. Our new friend here whom we call 'John in MN' is so fortunate to have found you and we are fortunate that he has shared his experience with us.
Re: In response to your questions.....Susan S on 6/20/04 at 20:32 (153568)
I just wanted to say I got a lot out of your post. Thank you so much!
Re: In response to your questions.....Marty in SLC on 6/20/04 at 22:04 (153571)
Thanks so much for sharing with us here.
Is there a web site locator per say or a phone number ..... Accociation type thing that lists doctors that have been trained in this procedure ... TFM. I live in Salt Lake City Utah and it's pretty slim pickings out here but this is how I found a good certified Ped. I just don't know if I can find someone as yourself here. I would fly there if it only took a week but for say 8 weeks now that would be tuff. Anyway thanks again.
Re: ps ... Dr SandellMarty in SLC on 6/20/04 at 22:28 (153572)
who would most likly know TFM? Physical therapist, Chiropractor, Sports practitioner or someone other then these???
Thanks so much,
Re: In response to your questions.....Elyse B on 6/21/04 at 07:05 (153576)
I would like the answers if you could to Dorothy's question. Specifically about seeing you: what can a patient who does not live near your practice realistically expect in terms of time needed (staying at a motel, for example) and any follow-up/maintenance?
Re: In response to your questions.....john h on 6/21/04 at 08:39 (153583)
Marty: I called about 8 Physical Thearapist in my city and at least half of them were familiar with TFM and said they used it. Problem is many can talk the talk but cannot walk the walk. The guy I am using clearly understands the procedure and is using it but not very much. Ultimately you will not know until you go to one and even then how do you know he/she is doing it like Dr. Sandel describes. He says in his post that if you are off just 1/2' or so you might as well be massaging the shoulder.
Re: Don't Take the RiskJohn from MN on 6/21/04 at 08:57 (153585)
Would you go to a Plastic Surgeon for a nose job if you were his second patient or he only did them twice a year. Same thing when someone is going to recondition for fascia tissue. Dr. Sandell does TFM 5 hours a day 6 days a week and has done this for years. That is why I chose him to work on my feet. You want someone with a lot of experience and there just isn't' very many people out there that have expertise.
Re: Don't Take the Risk Attn: Dr. Ed & Zjohn h on 6/21/04 at 10:13 (153594)
John from MN: Having been on this board from almost since the begining I have seen more cures posted for PF than I can remember. Many or most I have even tried and have traveled from Little Rock to New Jersery to St Louis to try a procedure. Reading Dr Sandels post he is clearly very informed and if he were within a couple of hundred miles I would be in his offices today. Finding a cure for PF would be a medical milestone as over 6 million people a year develop this disease. From my reading of his post it appears his treatment is more likely to help someone who has not had the disease to long. ESWT is much more successful with people who have not had PF for many years. The skeptic in me says if this works in a very high percentage of people why are not people all over the country jumping on the procedure? Anyone who can cure this problem for people with chronic PF on a consistent basis could become a millionare by just treating professional athletes and forget about the general population. Some things I would like to know: (1) What percentage of his patients does he provide a cure for which last for at least one year? (2) What is his success rate with patients who have had the disease for 2 years or more? (3) How many patients has he cured and how many received no benefit? (4) Are there any scientific studies to show how successful this treatment is for PF (5) This is not a new type of treatment and many people practice it. Normally if a practicioner finds something that really works he will stick with it and advertise it widely. Other than on this board I have never heard of TFM.
After haing questioned the success of this method which we should all do for any treatment I would certainly stand in line to try it if I find a number of people who state they have been cured and in particular the ones from this board who are apparently traveling to visit the Doctor. I do not question the science the Doctor writes. I question that any massage treatment for around 1-2 weeks could cure my bi-lateral PF which has stopped me in my tracks for 9 years. This would be a medical 'miracle'.
Medical miracles do happen so I wish the best to those who are headed his way and I anxiously await thier results. So far my PT who is performing TFM on me is performing no miracles and does profess he can. I do question his commitment to TFM as he seems more committed to conventional methods
Dr. Z and Dr. Ed where do you stand on TFM? Were you taught anything about it in medical school? If this procedure is highly successful why do you not add it as a procedure in your practice?
Re: Don't Take the Risk Attn: Dr. Ed & ZJohn from MN on 6/21/04 at 10:39 (153597)
I would have you ask Dr. Sandell your 5 questions since he is qualified to do so. Setup a time to talk to him on the phone; I think that's the best way. I have spent hundreds of hour over the past 5 years trying to fix my sever PF problem and was just as skeptical as you. Time is the best test for any treatment. I would suggest sitting back and wait and see as people on this board get their PF fixed by Dr.'s like Sandell and read their testimonials.
If you had told me 6 months ago that rubbing my feet with a brass knuckle like instrument would fix my PF I would have laughed in your face.
Let me tell me you my motivation for posting my treatment. Part of my healing process is to help others get their feet fixed. I have already gone through 5 very painful years not being able to walk much. I have talked to hundreds of 'qualified people about PF and found a solution. I hope you can learn from my experience. I would like to see 5 other people cured from PF as a part of my healing process. After that I hope those 5 will help 5 more people each. Once I help 5 people I am moving on because then I will have felt I have done my part.
I know of two people on this board; goose and Place who are currently being treated by Dr. Sandell for their PF problems. I highly recommend you get their email address and correspond with them about treatment. Then, one enough people are cured using his techniques I would suggest moving forward you getting cured.
I hope you find your answers because I know how painful it is living with PF. Good luck John h
Re: Don't Take the Risk Attn: Dr. Ed & ZElyse B on 6/21/04 at 10:45 (153598)
great post John and I could not agree with your more. Dr. Sandell DID say he cannot 'cure' PF but he did say has been successful with his treatments. We are lucky that Goose and Place are going out to Minnesota to try his procedure. And like you, I will be on a plane to Minnesota if they are 'cured.'
I, too have done a lot of research on this and called spoken to many podiatrists, chiropractors and physical therapists. Podiatrists do not use modalities for their treatment of PF. It is my belief that their first treatment is orthotics. Chiropractors are trained in ART, TFM, graston etc. and are more interested in the body's alighnment. The physical therapists I have spoken to use conventional methods, i.e., ultrasound, electronic stim, stretching and deep tissue massage. The ones I have spoken do not seem to have the great success with TFM as Dr. Sandell. I don't think Dr. Sandell has been clear as to how many treatments one needs and I don't think he can be. I think every case is different. I concur with you that 1-2 weeks of TFM does not seem logical in curing PF. I also agree with Place's posting that after 6-8 treatments of TFM, graston etc. if you are not having results, you will never have them and kudos to her doctor for actually admitting that.
In conclusion, I am confused and wish there was 'one' answer to this but there does not seem to be. It seems like there are many modalities to choose from and one has to be lucky to hit the right one.
I am going to keep trying until I find the one that works for me and hopefully I won't have to spend my summer in Minnesota!!!
Re: Don't Take the Risk Attn: Dr. Ed & ZJohn from MN on 6/21/04 at 11:07 (153600)
I agree with your post. I saw results within the second week of treatment when I walked 1/2 mile with the pain initially being a 10, then moving down to a 3. But I was not cured my any means. Remember, it took me 2 months of treatment to get me to the point where I was running/walking without any pain. The treatment is a continuous process of breaking scar tissue and letting it heal in the right way. Its not an overnight solution, but the tissue feels just like new.
Do not take my word for it that Dr. Sandell's treatment works. But take the word from many of his patients being cured.
Dr. Sandell did tell me that patents in their 70's are harder to cure since their tissue is not as elastic.
Re: Don't Take the Risk Attn: Dr. Ed & ZElyse B on 6/21/04 at 11:29 (153602)
we await Goose and Place's responses about their treatments with Dr. Sandell. At least we know it took you 2 months of treatment to get to where you have no pain. I am not sure how many of us on these boards can go to Minnesota for 2 months!!!
Re: Don't Take the Risk Attn: Dr. Ed & Zjohn h on 6/21/04 at 11:37 (153603)
I am pleased you posted On Dr.Sandel as this is the way we all find new methods of treating PF. It has worked for you and if I find a cure I will be singing it praises all over the board. Some posters have found help with some very different things but so far no one thing has helped every poster. I have always thought PF to be several different diseases much like cancer so in my mind there will never be one cure fits all. I do not think the diagnosis of PF to be an exact science so we start off with the problem of not know for sure what our pain is caused from. I remeber well that when we all heard about the new treatment of ESWT being performed in Canada I think most of us thought this might be the final answer. Of course it was not. It helped many, cured some. and did not help others at all. It remains a good alternative to surgery from which there is no return. With TFM there seems to be no downside and it appears to make medical sense. The problem seems to be finding someone who can perform it as Dr. Sandell prescribes. Traveling to a far away city and staying for a week or more is not very easy for most to do..
Re: Don't Take the RiskPlace on 6/21/04 at 12:00 (153604)
I have had many treatments of different modalities over the last past month. Although you may not find someone who is knowlegable in all of the areas but my be able to put together a team of people. For any massage, I would never go to a PT, but rather a massage therapist. they go longer, know more about deep tissue massage and do it for a living. Any of the 6 PT's I have been to got warn out after 5-8 minutes. I would call a local massage school for people who may be certified in certain areas. Most of the time the teachers at the school are the ones who are the best! Also, after having two sessions of someone trained in graston, I have to say I can be on my feet longer, it does not hurt as much. I may just be hopeful but I when ever I wear my night splints prior to my treatment I would always have to take my right boot off becuase my toes were pushing so hard on the top my toes would fall asleep! After the two sessions I can wear my right bood without any problems. I have no other explaination other than the treatment. To find someone trained in graston, you can go to there website or call them and they can give you a provider in your state. I only had 3 in mine!
Re: In response to your questions.....Marty from SLC on 6/21/04 at 12:13 (153605)
The chances that I find someone here in this state are slim and to find someone confident in it is another thing all together. I have read many post here over the year about deep tissue techniques from golf balls to art. (I must confess I was one of the first to sign up for that cream made from wheat that smelled like lemons.) When I came here at first there wasn't even a mention of EWST. Many come back and say they are pain free so it's my hope that I find something that works. I just want to get a start on what way to peruse this here in po dunk land and like the rest of you I await to see how the other 2 people going to Dr Sandell turn out. I guess the question I have is like you john how long have they had pf and are they chronic? I wish them the best!!!!
Re: Don't Take the RiskMarty from SLC on 6/21/04 at 12:18 (153607)
thanks for much for the leads Place !!!
I wish you the best in your treatment !!!!! That great to hear you might be improving!!!!
Re: Don't Take the Risk Attn: Dr. Ed & ZJohn from MN on 6/21/04 at 12:21 (153608)
I would only go to MN in the summer, the winters here are very cold.
Re: In response to your questions.....Place on 6/21/04 at 12:56 (153611)
John H, I don't know much about the TFM but when getting Graston, you as well as the Dr. can feel where the scar tissue is, there is no mistake about it. They can do a 'scan' and be both will make notations of where the bumbs are.
Re: Don't Take the RiskElyse B on 6/21/04 at 12:58 (153612)
Place, I had a massage on Saturday and I agree with you about Physical therapists and massage therapists. They go deeper and do it longer. There is the american massage association that has a web site. Place what time is your appointment with Dr. Sandell?
Re: In response to your questions.....Nancy J on 6/21/04 at 13:25 (153616)
Doc, I'm very impressed....
Re: Don't Take the Risk Attn: Dr. Ed & ZDorothy on 6/21/04 at 15:02 (153629)
I wish we could all afford to pool our money and send you to Minnesota for the probably needed 2 months for the best opportunity for these treatments with Dr. Sandell. I think if you could be fixed, there would be great jubilation. What about if we all pool our money and buy a little house to rent for all the PF/Achilles/ etc. sufferers to spend the necessary time to get treatment.... like a Ronald McDonald house idea.
I am just in wishful thinking mode for some realistic way for all of us to try this, rather than sitting here vicariously with those who can.
I wonder if John of MN could work with Dr. Sandell/staff to compile a state by state list of those whom Dr. Sandell knows of/trained with who do these techniques (TFM, Graston) - or some central reference source to find these practitioners. Not only cannot most of us spend months in MN, most of us cannot be calling all over the region long-distance, making cold calls to various chiropractors, massage therapists, etc. about if they know about the techniques, do them, are trained in them - and then begin a big experiment with them!
Re: Don't Take the Risk Attn: Dr. Ed & ZDr. Z on 6/21/04 at 16:31 (153639)
I haven't heard of this treatment but I am willing to keep an open mind. I am in contact with a podiatrist who has been using Bowen's technique. This podiatrist is willing to teach me and help me learn this technique. The way I look at this is that there is no one treatment for everyone and there is going to be a combination of therapies to help alot but NOT all.
I just spent three days in Jacksonville, Floriday studying with a pain managment specialist( retired navy what else). I have learned to identify and treat local nerve entrapment that can contribute to ' plantar fasciitis' We discussed TTS but I am not ready to treat this with cryotherapy . So learning is something to do everyday and each day brings us more information.
I don't want to blow everyone bubble but I just don't see how this Friction massage can help everyone or anyone at this stage of my observation, but I am always willing to learn
Re: Don't Take the RiskMarty in SLC on 6/21/04 at 18:30 (153643)
great thanks !!!!
Re: Don't Take the Risk Attn: Dr. Ed & ZEd Davis, DPM on 6/21/04 at 19:47 (153654)
There are so many different names for massage techniques but the applications themselves are not necessarily very different. I use some massage in my office as an adjunctive technique. I think it is a valuable thing to have in one's 'armementarium' of treatments but it not something that I view as a 'stand alone' treatment. I believe that a multifaceted approach to PF treatment is best, utilizing a combination of modalities.
I don't see many treatments out there that I would view as 'magic bullets.' Medicine is certainly an art and a science and the responses to various treatments varies widely among the public. One can find a segment of the population that responds very well to a particular technique and become enthusiastic supporters of such techniques. Sometimes, a practitioner needs to apply a technique, measure the patient response, then modify and refine the technique based on that response.
Re: In response to your questions.....john h on 6/21/04 at 21:33 (153662)
Place: I have no doubt I have some scar tissue because I can feel it and for good reason I had surgery. I know you can release adhesions with massage but I question whether you can remove scar tissue from surgery. I suspect after surgery you will always have some scar tissue remaining. You may reduce it somewhat if you can massage the effected early on while the body is laying down the scar tissue but once it is formed I am not so sure you can massage it away.
Re: Don't Take the RiskDr. Z on 6/22/04 at 07:38 (153680)
I hate my feet massaged but when other areas of the body are tight this can contribute to lower extremity pain ie knees, ankles and feet. I also feel that massage produces an analgesic effect causing reduction in pain whether short, intermediate or hopefully long term.