Search Results

Acupuncture works well for many types of lower back pain and is probably 65% of what we treat on a daily basis, so we can state with confidence in the majority of cases that acupuncture works well for low back pain relief. Let's start with an anatomy 101 lesson: your back is made up of soft tissue (muscles, ligaments, tendons) and bone, blood vessels and nerves. There are also several organs located deep to the low back, which is important to consider when diagnosing the root cause of pain. Some causes of lower back pain are: Strains to soft tissue Disc herniations Vertebral fractures Inflammation of the periosteum at the facet joints Disc degenerations: osteoarthritis, stenosis, spondylolisthesis Referred pain from kidney or gallstones Your low back pain can run the spectrum from feeling dull, achy, sharp, radiating, or electrical (from nerve compression), any of which can be accompanied by numbness and tingling and/or weakness. How does western medicine treat this? Diagnostic tests will identify the location and nature of the problem using technology: x-ray, CT scans, MRIs, or myelogram. If the problem is not severe, the course of treatment for mild low back pain is rest, medications (NSAID, anti-inflammatories, muscle relaxers), ice and heat packs, and physical therapy exercises. The diagnostic test results are a valuable tool to identify what we’re dealing with, but it is by no means a requirement. Most people come in for treatment with mild low back pain to get out ahead of the condition. In general,, acupuncture works by improving circulation, reducing local inflammation, and stimulating the body’s natural signaling for tissue repair. On average, our patients start to feel better after 2 to 3 sessions, though some find relief after the first session. Movement is an important part of therapeutic treatment to speed recovery, and we recommend gentle exercises to maintain core strength and work the range of movement in the affected area. In addition to straight-up acupuncture, your low back pain issue might call for massage, cupping, gua sha, electroacupuncture, topical pain-reducing herbs, infrared heat, passive stretching, and injection therapy.

Stress is a lived experience for many in our all-too-busy lives. Acupuncture is a transformational tool that can help manage the bodily sensations and mental activity that is so familiar in the presence of stress and anxiety. How does acupuncture affect the body so strongly?   Acupuncture slows down the sympathetic nervous system, the part of our brain that that is ever-alert for survival, and gives the parasympathetic nervous system dominance, the part that works on healing and repair when we sleep. The short term effects include a slower heart rate, less muscle tension, and an overall feeling of calm and well-being at the end of a treatment session. These effects become more long lasting with repeated treatments, tone the nervous system by reinforcing the natural balance between activity and rest.  This sounds too good to be true. How does acupuncture accomplish this? Let’s take a deeper dive: Acupuncture modulates neuro-chemicals by stimulating the release of several key neurotransmitters and hormones that directly affect stress and mood. Acupuncture balances the Hypothalamic-Pituitary-Adrenal Axis (HPA) System in the brain by slowing hyperactivity, regulating cortisol levels, and reducing systemic inflammation. In short, acupuncture helps rebalance the autonomic nervous system, modulate stress hormones, and enhance mood-regulating neurotransmitters. The stress-relieving effects of acupuncture are now well supported by both clinical studies and neurobiological research. Here’s a research study that breaks this down a little more.  To summarize : Shifts the nervous system toward relaxation (parasympathetic dominance) Releases endorphins and regulating serotonin, GABA, and cortisol Calms overactive brain regions involved in fear and stress Supports emotional balance through HPA regulation And if reading scientific language makes your eyes glaze over, and/or you’re more of a visual learner, watch this short video of how stress affects the body instead. There are several actionable methods that work to manage stress, but I have found that when someone is feeling very anxious, it’s not easy to pivot and downshift. Acupuncture puts you in a zone that clears the mind, and when you’re able to think more clearly, self-agency can be reclaimed. My experience of treating patients over years of practice corresponds with excellent research that supports my observations and outcomes. If you want some examples, read through some of our Reviews . While many studies support acupuncture’s role in stress reduction, its effectiveness can vary from person to person. If you’re considering trying acupuncture to manage stress, it’s advisable to consult with a licensed and experienced acupuncturist.

Acupuncture impacts stress by its indirect influence on the nervous system. It has the ability to even out the high and lows of energy, attitude and mood. This post is covers the highlights of a research study done by Ladan Eshkevari and her team at Georgetown University Medical Center. Her work explores the effects of stress on the body through the lens of the endocrine system. This study pinpointed which part of the brain is involved when acupuncture relieves stress. Blood tests and behavioral observation were the common methods used to collect data and compare results across four groups. Each group had different use or no use of acupuncture, as well as different exposures to stress. The blood tests measured levels of two hormones in the hypothalamus-pituitary-axis (HPA): corticosterone (CORT) and stress-induced circulating ACTH. The stress on the lab rats was basic: exposure to colder temperatures. The behavioral tests placed each group in an open box to observe their behavior after receiving acupuncture, and a forced swim test that placed the subjects in a bucket of water to see how resilient they were in the face of a life-and-death challenge. The group given acupuncture had lower levels of the hormones in their bloodstream, and the same group was also swam the best in the bucket and were the most relaxed in the box, exploring their new surroundings and not retreating to the corners like their more anxious counterparts. This study has a third part, comparing acupuncture’s effects with anti-anxiety/anti-depression SSRIs. Interestingly these drugs and acupuncture follow the same pathway in the HPA, the pathway that affects mood. The HPA regulates hormones by a feedback mechanism that detects chemical levels and adjusts them automatically as needed o help the body function as neutral and steady as possible. An example of this might be calcium in the blood: too much and the HPA directs the excess to be stored in the bone, and not enough and the directive is sent to pull some out of the bone and put it in the bloodstream. The research found that while the SSRIs rely on this feedback loop, acupuncture does not. Instead, it is simply its presence that elicits the regulation of hormones. This finding is remarkable and it has the wider implications in bioscience that are yet to be studied.

For the past decade or so, "stress and anxiety" are one of the conditions almost every new patient writes on their intake form. These feelings, of stress and anxiety, is a lived experience for so many of us, and acupuncture can be used as a transformational tool to alleviate these feelings and help shift one's psyche in a more fruitful direction. As a practitioner, I believe this is the highest use of this ancient art. My experience of treating patients over years of practice corresponds with excellent research that supports my observations and outcomes. If you want some examples, read through some of our Reviews .   There are several actionable methods that work to manage stress, but I have found that when someone is feeling very anxious, it’s not easy to pivot and downshift. Acupuncture puts you in a zone that clears the mind, and when you’re able to think more clearly, this has a dimensionally net-positive effect on your life.   Acupuncture helps reduce the feelings of stress and anxiety by slowing down the ever-alert part of the nervous system, and re-introducing that part of ourselves that is present and receptive. Here 's how it works:   Acupuncture reduces the stress we experience in our physical body in several ways : by  r egulating the nervous system, by down-regulating activity in the emotion center of the brain, by releasing endorphins and balancing hormones in the endocrine system, and by improving circulation which in turn relaxes the muscles and fascia. Here's a brief video explanation of how stress affects the body .   Acupuncture is a meditative experience: many people find when they experience acupuncture for a period of time on the table their minds relax and empty, leading to a feeling of well-being. This is the experience of downshifting from “fight or flight” (the sympathetic nervous system) to “rest and digest” (the parasympathetic nervous system). Here's a deeper dive into how acupuncture impacts stress .     Typically, every acupuncture treatment is tailored to the individual, and will address the symptoms that potentially intertwine with stress. For example, some of the most common “side effects” of stress that I see are frequent headaches including migraine headaches, digestive issues, insomnia, muscle pain, or chronic pain.   While many studies support acupuncture’s role in stress reduction, its effectiveness can vary from person to person. If you’re considering trying acupuncture to manage stress, it’s advisable to consult with a licensed and experienced acupuncturist.

Calm the Nervous System with Acupuncture This is part of our series on stress and anxiety, where we cover basic physiology, the neuroscience, and how acupuncture can help you redirect the normal stress towards a better state of health. How Stress Can Make You Sick is a video that explains how all the body systems are affected by stress, which may act as a wake up call to change some behaviors and habits. Stress is not only a state of mind, it’s experienced in many parts of the body. Stress speeds up the aging process and suppresses the immune system, making you more vulnerable to disease and robbing your birthright to a good quality of life. Are you motivated to look at the stress in your life and start bringing it under control? From TED-Ed creator Sharon Horesh Bergquist : Headaches, IBS, insomnia, brain fog, high blood pressure, palpitations, and frequent colds are just some of the physical byproducts of chronic stress. We need our bodies to step up and react to real stressors when they present. The damage of prolonged, unrelenting everyday stress wreaks havoc on your body, which is beautifully illustrated in this video. Think about the stresses that trigger you daily and whether you can make changes in you and around you that help bring things down a notch or two. Experience what it’s like to live in a little more calm for a little while and see if that suits you better. Some lifestyle changes like adequate sleep, quiet time alone, choosing a “cleaner” diet, and exercising regularly will help. These are the foundation which can gradually be incorporated for long term changes. Acupuncture can help bring you into a calmer state because it has a strong effect on the nervous system. Research has demonstrated its modulating effect on neurochemicals of the nervous and endocrine systems to even out our response, experienced as slower breathing, calmer thinking, and smoother emotions. This natural result is tangible and simply feels good.

Acupuncture helps reduce and prevent headaches and migraines  by addressing both the underlying imbalances  and the symptoms. Acupuncture Is Especially Helpful For: Chronic migraine sufferers looking to reduce medication use Tension-type headaches (stress and posture-related) Hormonal headaches (PMS, perimenopause) Headaches triggered by neck tension or digestive imbalance Modern research has established several ways acupuncture works physiologically. Here are the biomedical mechanisms that explain how acupuncture for headaches: 1. Pain Modulation Acupuncture stimulates the release of endorphins, serotonin, and dopamine , which naturally reduce pain and elevate mood. 2. Regulates Nervous System Activity Acupuncture down-regulates the sympathetic nervous system  and helps modulate the trigeminovascular system , which is involved in migraine pain pathways. 3. Improves Blood Flow Enhances cerebral circulation  and oxygen delivery to the brain, helping reduce vascular factors linked to migraines. Many conditions can cause this, the most common of which is tight neck and upper back muscles. 4. Reduces Inflammation Lowers levels of pro-inflammatory cytokines like TNF-α and IL-6 that can trigger or worsen headaches. 5. Balances Neurotransmitters Migraine sufferers often have fluctuations in serotonin and other neurochemicals, which acupuncture helps regulate.     Clinical Evidence on Outcomes with Acupuncture Clinical trials have shown that regular acupuncture  (e.g., weekly sessions over 6–8 weeks) can significantly reduce the frequency, intensity, and duration  of both migraines and tension headaches. In some studies, acupuncture is as effective or more effective than prophylactic medications —with fewer side effects.

Acupuncture supports post-concussion healing and other brain injuries by stimulating the body's natural healing processes and by restoring balance within the nervous system. Further, it has been shown to promote neuroplasticity and to be neuroprotective. In my practice, I have witnessed remarkable responses after the application of acupuncture as a treatment. Some conditions that respond well are many types of headaches, including migraine headaches, concussion, and the aftereffects of Long Covid such as difficulty concentrating and anxiety. For brain injuries, migraine headaches, and other neurological disorders, acupuncture works by: Reducing inflammation Promoting blood flow and oxygen delivery Modulating pain and stress pathways Supporting the brain's ability to heal and adapt   Here’s how acupuncture helps in conditions involving brain injuries : Acupuncture has been shown to promote neuroplasticity, helping the brain form new neural connections to compensate for damaged areas. Acupuncture rewrites the “code” in the part of your brain that perceives pain, as your real pain is relieved. Acupuncture reduces oxidative stress and inflammation, which are common after brain injuries. Acupuncture increases blood circulation to the brain, helping deliver oxygen and nutrients necessary for healing. Acupuncture evens out the autonomic nervous system (ANS) by reducing the overactive sympathetic (fight-or-flight) response and allowing the parasympathetic (rest-and-digest) supremacy. Being less stressed is helpful to overall healing. Acupuncture is beneficial when experiencing cognitive issues such as memory and difficulty concentrating. It is also useful for anxiety and mild depression.   Here’s how acupuncture helps migraine and other types of headaches : ·       Acupuncture modulates pain by releasing neurotransmitters that play a role in pain perception, and it works deep within two distinct areas, the hypothalamus and brainstem, to regulate pain pathways. ·       Acupuncture improves circulation, reducing vascular constriction or dilation linked to migraines. Acupuncture follows the same pathway in the brain as serotonin, modulating serotonin levels, which plays a significant role in migraine pathophysiology. ·       Acupuncture reduces inflammation by lowering levels of inflammatory markers and decreasing the inflammation in blood vessels and surrounding tissues that contribute to migraines and other types of headaches. Acupuncture reduces stress and muscle tension, two very common headache triggers, especially in the head, neck, and shoulders. Research Evidence ·       For brain injury, research supports its role in enhancing functional recovery, although it is often used as a complementary therapy. That is why, when we see more complex cases, we refer patients to Plasticity Brain Centers . Plasticity Brain Centers use Neuroplasticity-Based Therapy, which focuses on stimulating neuroplasticity to help the brain form new pathways and connections in the brain. Whether you’re recovering from a neurological injury, managing a condition, or simply looking to improve cognitive function, Dr. Shaun Kornfeld and his team  will assess and customize your treatment, using the latest technology available. Several studies have shown that acupuncture is effective for reducing the frequency, intensity, and duration of migraines, and it may even outperform some medications with fewer side effects. As you would with any medical intervention, when you are considering a holistic-based approach, make sure you are working with a licensed healthcare professionals that are familiar with neurological and headache disorders.

Research and experience recognize that acupuncture improves your chances of IVF success. This is why acupuncture is increasingly being used as an adjunctive therapy to support fertility, particularly during the IVF process. Acupuncture improves overall reproductive health by: Improving blood flow to the uterus and ovaries to improve implantation success and nourish the developing fetus Regulating reproductive hormones in the hypothalamic-pituitary-ovarian axis (HPA), which plays a crucial role in hormonal balance. This improves ovarian response during IVF and supports the luteal phase for implantation. Improving the quality and quality of cervical mucus Reducing stress in part by lowering cortisol levels, calming the mind and relaxing the body and leading to improved metabolic function Improving follicular function , resulting in better quality eggs Thickening and improving the endometrial lining , making it more receptive to embryo implantation. Increasing implantation rates before and after embryo transfer Reducing the side effects of IVF medications Addressing underlying conditions that may be contributing to infertility Helping prevent miscarriage and reducing stress during those critically important first 12 weeks of pregnancy. Acupuncture is safe when performed by a qualified practitioner. It is essential to consult with both your medical team and acupuncturist to get the most effective treatment plan. I am board certified in both acupuncture and Chinese herbal medicine. Chinese herbal formulas are a superfood supplement to support conception prior to the IVF process.

What is the Fascia Plane? Fascia is an interconnected, thin layer of connective tissue that envelops muscles, nerves, and organs. The fascia is actually one, contiguous sheath of connective tissue as it wraps around all of these structures. This plane is a dynamic network of tissue that transmits mechanical and biochemical signals throughout the body, and it plays a critical role in movement, stability, and communication between body systems.   How Does Acupuncture Interact with the Fascia? When an acupuncture needle is inserted at a precise location, it stimulates a cascade of physiological responses in the fascia plane. These responses are mechanical, biochemical electrical, reparative, and neurological.   1)     MECHANICAL  stimulation: when the needles are inserted, they pass through several layers of fascia, triggering receptors in the local connective tissue. The activation of these receptors is received as a signal in the brain, which sends back the message: “make more cells of that type of tissue in that area.” 2)     BIOCHEMICAL  responses: the insertion of needles activates the immune system to begin its healing response by releasing anti-inflammatory agents and immune cells, which have been shown to reduce pain and promote tissue repair. Additionally, acupuncture releases endorphins and neurotransmitters, which can alleviate pain and regulate the autonomic nervous system.   3)     ELECTRICAL  : fascia is piezoelectric, meaning it generates an electric charge in response to mechanical stress (e.g., needle insertion). This effect might explain how acupuncture impacts bioelectrical fields, improving cell-to-cell communication within the body. 4)     REPARATIVE : adhesions form in the connective tissue as a result of injury or repetitive stress, and acupuncture can release these adhesions, restore normal tissue mobility and alignment, reducing pain and dysfunction in the affected areas, which explains it’s unique ability to treat chronic pain, muscle stiffness, and restricted movement. 5)     NEUROLOGICAL : the fascia plane is rich in nerves, and contains various types of sensory receptors. Acupuncture interacts with these receptors, via the neuro-fascial feedback loop, and is another reason why acupuncture is effective for conditions related to tension, stress, and chronic pain.     Summary Acupuncture has a unique ability to interact with the fascia in a number of ways that explain why it is so useful for pain relief and tissue recovery.

Acupuncture is a natural treatment for IBS, which is a condition of alternating diarrhea and constipation, accompanied by symptoms of indigestion, bloating and abdominal pain. Acupuncture has the unique ability to regulate the nervous system, resulting in both improved digestion and less stress and anxiety. What is IBS? IBS is a condition that is diagnosed based on the symptoms. These symptoms include: abdominal pain or discomfort and bloating caused by constipation and diarrhea. IBS occurs episodically, often alternates between diarrhea and constipation, and individuals with IBS lean towards one of these most of the time.   Why Causes IBS? IBS is a condition of hormonal and neurotransmitter signaling getting scrambled, which then affects the digestive system in these ways: 1. Motility : the result of signaling being off, can be either rapid (diarrhea) or slowed (constipation) transit time in the gut. Acupuncture has been shown to improve gastrointestinal motility for regular bowel movements. This can be particularly beneficial for individuals who suffer from alternating episodes of diarrhea and constipation, as the treatment helps restore normal digestive rhythms. 2. Reducing Stress : affecting the frequency of life stress and/or poor ability to process stress. Acupuncture has a unique ability to regulate the nervous system, which in turn promotes the experience of calm and wellness. By turning down the sympathetic response and strengthening the parasympathetic response, acupuncture can help reduce the frequency and intensity of IBS flare-ups linked to stress.   3. Alleviating Pain : one of the hallmark symptoms of IBS is abdominal pain and cramping. Acupuncture stimulates the release of endorphins, the body’s natural painkillers, reducing the perception of pain. Additionally, it may modulate pain pathways and improve the body’s pain tolerance, offering relief from chronic discomfort.   4. Balancing Hormones and Neurotransmitters : the gut and brain are closely connected through the gut-brain axis, where hormonal imbalances can directly affect digestion. Acupuncture regulates key hormones and neurotransmitters involved in digestion, including serotonin, which plays a role in gut motility and sensitivity.   5. Reducing Inflammation : chronic inflammation in the digestive tract is thought to contribute to IBS symptoms. Acupuncture has anti-inflammatory properties that can help reduce gut inflammation, easing symptoms such as bloating, cramping, and discomfort.   What Does the Research Say? While more extensive clinical research is needed, there are promising studies supporting acupuncture’s role in managing IBS. A study published in the American Journal of Gastroenterology found that patients with IBS who received acupuncture experienced significant improvements in their symptoms compared to those who did not receive acupuncture. Additionally, several reviews have highlighted acupuncture’s effectiveness in reducing pain, regulating bowel movements, and improving the overall quality of life for IBS sufferers.   Summary: Integrating Acupuncture with Other IBS Treatments Acupuncture can be used as a stand-alone treatment or in conjunction with other therapies, such as dietary changes, herbal supplements, and lifestyle modifications. Because IBS is a multifaceted condition, a comprehensive, integrative approach is often the most effective way to manage symptoms and improve digestive health.   The natural, drug-free option of acupuncture addresses both the physical and emotional components of IBS, makes it a valuable option for those seeking alternative treatments.

Joint pain can be debilitating, affecting every aspect of your daily life. And that’s an exhausting way to live. Whether it's due to arthritis, an injury, or overuse, finding effective and long-lasting relief is crucial. One ancient yet increasingly popular method for managing joint pain is acupuncture. This treatment, rooted in Traditional Chinese Medicine (TCM), offers a natural approach to pain relief and healing. In this blog, we'll explore how acupuncture can help alleviate joint pain and improve your overall well-being. How Acupuncture Helps Joint Pain Pain Relief : Acupuncture stimulates the release of endorphins, the body's natural painkillers, and other neurotransmitters that help reduce pain. Inflammation Reduction : The treatment can help decrease inflammation in the affected joints, alleviating swelling and discomfort. Improved Blood Circulation : Acupuncture enhances blood flow to the injured or painful areas, promoting healing and reducing stiffness. Muscle Relaxation : By targeting specific acupoints, acupuncture can relieve muscle tension around the joints, providing further pain relief and improved mobility. Common Joint Pain Conditions Treated with Acupuncture Osteoarthritis : Often affecting the knees, hips, and hands, osteoarthritis can cause significant pain and stiffness. Acupuncture can help manage these symptoms and improve joint function. Rheumatoid Arthritis : This autoimmune condition leads to chronic inflammation in the joints. Acupuncture can help reduce pain and inflammation, complementing other treatments. Tendinitis : Inflammation of the tendons, such as in tennis elbow or Achilles tendinitis, can benefit from the anti-inflammatory and pain-relieving effects of acupuncture. Bursitis : Inflammation of the bursae, the fluid-filled sacs that cushion the joints, can be eased with acupuncture, reducing pain and improving movement. Supporting Modalities In addition to acupuncture, other treatments and lifestyle changes may be recommended to enhance the effectiveness of your joint pain management plan. These may include: Herbal Medicine : TCM often incorporates herbal remedies to support joint health and reduce inflammation. Physical Therapy : Combining acupuncture with physical therapy can help strengthen the muscles around the joints and improve mobility. Diet and Exercise : Maintaining a healthy diet and staying active can support joint health and prevent further pain. Conclusion Acupuncture offers a natural, effective, and holistic approach to managing joint pain. By addressing the root causes of pain and promoting the body's natural healing processes, acupuncture can provide significant relief and improve your quality of life. So don’t let pain hold you back, try acupuncture and feel the difference! If you're ready to stop struggling with pain, contact us through the form or give us a call to book your acupuncture session today. References 1. Vickers, A. J., et al. (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine , 172(19), 1444-1453. 2. Zijlstra, F. J., et al. (2003). Anti-inflammatory actions of acupuncture. Mediators of Inflammation , 12(2), 59-69. 3. Meng, Z., et al. (2013). Acupuncture improves the microcirculation of lower extremities in patients with arteriosclerosis obliterans. Journal of Traditional Chinese Medicine , 33(4), 450-453. 4. Tough, E. A., et al. (2009). Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomized controlled trials. European Journal of Pain , 13(1), 3-10.

Tom Messina specializes in treating sports injuries and neck issues. His hallmark is his exceptional care and customization of techniques. He offers stand-alone massage, or a combination of acupuncture and massage.   The Synergy of Acupuncture and Massage Therapy Acupuncture and massage therapy each offer distinct benefits for pain management. When combined, their effects are amplified, providing a comprehensive treatment that addresses both the symptoms and the root causes of pain. Benefits of Massage Therapy for Sports Injuries Athletes and active individuals often face sports-related injuries like muscle strains and joint pain. Massage therapy can: · Reduce Muscle Soreness: Eases stiffness and soreness, improving recovery and performance. · Enhance Flexibility: Keeps muscles supple and joints flexible, preventing injuries. · Speed Recovery: Improves blood flow and lymphatic drainage, promoting faster healing. · Break Down Scar Tissue: Enhances mobility and reduces discomfort.   Addressing Neck Issues with Massage Therapy Neck pain often results from poor posture, stress, or injury. Massage therapy can: · Relieve tension and stress that underlie headaches and pain · Improve posture by addressing and correcting muscle imbalances · Reduce chronic neck pain by releasing tight muscles · Increase muscle and joint mobility and range of motion, making everyday activities more comfortable   Adding massage therapy to our acupuncture practice enhances our commitment to providing comprehensive care. We look forward to helping you achieve your health goals with our integrated healing approach. You can call (303) 888-5764 to get started, or contact us through the form under " Contact Us ."   References 1. National Center for Complementary and Integrative Health. (2020). Acupuncture: In Depth.  https://www.nccih.nih.gov/health/acupuncture-in-depth . 2. Vickers, A. J., et al. (2018). Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The Journal of Pain, 19(5), 455-474.  https://www.jpain.org/article/S1526-5900(17)30672-4/fulltext . 3. Field, T. (2014). Massage therapy research review. Complementary Therapies in Clinical Practice, 20(4), 224-229.  https://www.sciencedirect.com/science/article/pii/S1744388114000737 . 4. Moyer, C. A., et al. (2004). A Meta-Analysis of Massage Therapy Research. Psychological Bulletin, 130(1), 3-18.  https://pubmed.ncbi.nlm.nih.gov/14717648/ .