Back Clinic Integrative medicine Team. It is the practice of medicine that focuses on the whole person and utilizes all appropriate therapeutic approaches, healthcare practitioners, and disciplines to achieve optimal healing and health. It combines state-of-the-art and conventional medical treatments and other carefully selected therapies because they are effective and safe.
The goal is to unite the best of conventional medicine and other healing systems/therapies brought from cultures and ideas. This type of medicine is based on a model of health and wellness compared to a disease model. Integrative medicine is geared to the use of low-tech, low-cost interventions.
This model recognizes the critical role of how the practitioner-patient relationship plays in a patient’s healthcare experience. Its purpose is to care for the whole person by considering all of the interrelated physical and nonphysical factors that affect health, wellness, and disease. These include psychosocial and spiritual factors in people’s lives.
Proponents of mindfulness-based stress reduction claim it can improve relationships, mental health, weight and more. But, one complaint it’s unlikely to fix is lower back pain, researchers now say.
Lower back pain doesn’t respond to the programs, which embrace meditation, heightened self-awareness and exercise, according to a review.
Although short-term improvements were reported, “no clinical significance” was found in terms of overall pain or disability when mindfulness was compared to standard treatment, said study lead author Dennis Anheyer. Anheyer is a psychology research fellow in the faculty of medicine at the University of Duisburg-Essen in Germany.
About eight out of 10 American adults will experience lower back pain at some point in their lives, according to the U.S. National Institute of Neurological Disorders and Stroke. Roughly one in five of them will struggle with chronic lower back pain, lasting three months or more, which is a major cause of job-related disability.
Because no sure-fire treatment of back pain exists, many patients try complementary therapies such as mindfulness.
Mindfulness and Stress Reduction for Back Pain
Mindfulness programs, which are growing in popularity in the West, derive from the Buddhist spiritual tradition and are used to treat pain. They include sitting meditation; walking meditation; hatha yoga and body scan along with focusing attention sequentially on different parts of the body.
The seven studies that were reviewed involved close to 900 patients who had lower back pain for at least three months. Six of the studies were conducted in the United States; the seventh in Iran.
Some patients were offered standard back pain treatment, such as physical therapy and exercise routines that aim to strengthen the back and abdominal muscles; prescription and over-the-counter pain medications; ice packs and heat packs; and spinal manipulation and/or massage (chiropractic care). In some cases, surgery is recommended for chronic back pain.
Other patients engaged in mindfulness programs aimed at stress relief. Six of the programs were variations on an eight-week program developed at the University of Massachusetts. Most had a weekly 2.5 hour group session; one also had a day-long silent retreat.
Practitioners were also encouraged to engage in 30 to 45 minutes of meditation at home, six days a week. “We found that mindfulness-based stress reduction could decrease pain intensity at short-term, but not at long-term,” said Anheyer. Despite the negative findings, Michigan orthopedist Dr. Rachel Rohde isn’t ready to rule out mindfulness as a back-pain treatment.
The size of the research review was relatively small, said Rohde, an associate professor of orthopedic surgery at the Oakland University William Beaumont School of Medicine.
Also, “pain” is perceived differently by everyone, she said. In the case of chronic pain, people tend to try everything they can to feel better, making it difficult to figure out exactly what works and what doesn’t, she added.
The idea that changing the way you think can change the way you feel — the premise of cognitive behavior therapy — is used as a treatment for chronic pain, Rohde continued. “I think that mindfulness-based stress reduction is somewhat of an extension of this and probably would work very well for some and perhaps not so well for others,” she added.
The researchers behind the new review suggested that future studies look at specific components of mindfulness programs, such as yoga and mindful meditation. Yoga, they said, has been shown to increase function and decrease disability in patients with low back pain.
SOURCES: Dennis Anheyer, M.A., B.Sc., psychology research fellow, faculty of medicine, University of Duisburg-Essen, department of internal and integrative medicine, Kliniken Essen-Mitte, Essen, Germany; Rachel S. Rohde, M.D., associate professor of orthopedic surgery, Oakland University William Beaumont School of Medicine, Michigan Orthopaedic Institute, P.C., Royal Oak, Michigan; April 24, 2017, Annals of Internal Medicine
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Additional Topics: Whole Body Wellness
Maintaining overall health and wellness through a balanced nutrition, regular physical activity and proper sleep is essential for your whole body�s well-being. While these are some of the most important contributing factors for staying healthy, seeking care and preventing injuries or the development of conditions through natural alternatives can also guarantee overall health and wellness. Chiropractic care is a safe and effective treatment option utilized by many individuals to ensure whole body wellness.
Doctor of Chiropractic, Dr. Alexander Jimenez examines people that see�a chiropractor and their reduced�usage of opioids and other types of drugs.
The draft Guidance for Prescribing Opioids for Chronic Pain, issued in December 2015 by the U.S. Centers for Disease Control and Prevention, included �many complementary and alternative therapies (e.g., manipulation, massage, and acupuncture)� among its recommended non-pharmacologic approaches. However, when the final Guidance was released three months later, manipulative therapy and its 75,000 licensed chiropractic practitioners was not directly referenced. A recent study from James �Jim� Whedon, DC, MS, pictured, suggests that the CDC harmed its mission with its excision of explicit reference to manipulation. Patients using chiropractors were less likely to use prescription opioids.
Whedon is currently a researcher at the Southern California University of Health Sciences, and is co-chair of the Research Working Group of the Academic Collaborative for Integrative Health. He is a relatively rare resource in the integrative health community, as a specialist in diving into huge data sets of insurers and seeking to extract useful information. Whedon is a veteran of arguably the most important research center in this type of work, The Dartmouth Institute at the Geisel Medical School at Dartmouth College.
Whedon�s research began with awareness that �little is known about the comparative effectiveness of non-pharmacological care for low back pain as a strategy for reducing the use of opioid analgesics.� What is well known, as Whedon shared in his poster and presentation at the 2016 conference of the Academy of Integrative Health and Medicine, is that patients with such pain are swimming in opioid prescriptions. Whedon�s presentation included a Baskin-Robbins-like list of 39 opioid varieties. He postulated that opioid use would be less likely among those receiving chiropractic care.
Association Between Utilization Of Chiropractic For Back Pain & Use Of Prescription Opioids
Preliminary results of a health claims study,� Whedon reports what he found through examining the New Hampshire All Payer Claims Database.� Of roughly 33,000 adults registered as having low back pain, slightly over a third saw a chiropractor. Of these, 38 percent had at least one opioid prescription. Of those who did not see a chiropractor, 61 percent had at least one opioid prescription.
The core question that interested Whedon was how many prescription fills the two sets of insured patients received. Those whose opioid prescription was integrated with chiropractic care had an average of 3.9 fills. Those who did not receive chiropractic manipulative therapy averaged 8.3 fills per patient. He estimated that the average per person opioid charges were $88 for those using chiropractors. The figure was $140, or 60 percent higher for those not using chiropractic care.
Whedon�s conclusions were, first, that the likelihood of filling a prescription for a high-risk drug of any type was 27 percent lower. Secondly, the likelihood of filling a prescription for an opioid analgesic was 57 percent lower in the chiropractic-using population.
�These are preliminary results,� Whedon cautioned. �We intend to analyze the data further, applying robust methods to reduce the risk of bias that can result from other differences between people who use chiropractic care and those who do not.�
Comment: While Whedon takes care to note that �no causal inferences can be made,� the associations should be of real interest to the CDC and other policy makers. A follow-up study might attempt to compare the whole costs of the chiropractic-using population and those who didn�t.� These costs could include, on the one hand, the cost of chiropractic treatment, and on the other, the costs of other medications or treatment that may be prescribed for those on longer-term opioid treatment who may end up cycling into the addiction.
Conventional medicine is necessary to cure disease, but if you really want to stay healthy, you should incorporate treatments from the field of need to incorporate curing illness, but if you want to stay as healthy you should incorporate practices from the field known as integrative medicine as well, a top expert says.
“The field of integrative, or complementary, medicine, grew out of what used to be known as ‘alternative health,’ but the concepts we use today are based on scientific evidence,” Dr. Ashwin Mehta tells Newsmax Health.
Conventional medicine, known also as Western medicine, is a system in which medical doctors and other healthcare professionals treat symptoms and diseases using such means as drugs, radiation or surgery.
In contrast, the term “alternative medicine” describes a range of medical therapies that are not regarded as orthodox by the medical profession, such as herbalism, homeopathy, and acupuncture.
“In the 1970s, the alternative medicine gained traction in the U.S. as a pushback against the biochemical paradigm that was becoming associated with medicine,” says Mehta, medical director of integrative medicine at Memorial Healthcare System in Hollywood, Fla.
“But, on the other hand, the realization was growing that there might be something of value in these ancient healing traditions, and so we should scientifically evaluate them.”
When some alternative therapies were held up to this scrutiny, they were found to be baseless, says Mehta. On the other hand, others were found to be valuable. These have since been known as integrative, or complementary therapies, he adds.
“Integrative medicine uses only the therapies that have been found to have scientific validity,” says Mehta.
He likes to explain this concept by using an example in cancer treatment.
“If the body is a garden and cancer is an unwelcome weed, the job of the oncologists (cancer doctors) is pluck out the weed and our job is to make the soil of the garden inhospitable to the weed ever coming back,” he says.
One of the most valuable adjuncts that integrative medicine offers today’s patient is the ability of these therapies to reduce inflammation.
Inflammation is the same reddening process you see if you cut your finger. But there also is an invisible type of inflammation, known as “chronic bodily inflammation,” which occurs inside your body and cannot be seen.
Such inflammation is increasingly viewed as the culprit in the development of cardiovascular disease, diabetes, and cancer as well, notes Mehta.
“Today, we use the term ‘metabolic syndrome,” to describe a number of conditions, including high cholesterol, high blood sugars, high blood pressure and obesity, that increase the risk of cardiovascular disease, diabetes and cancer,” says Mehta.
What these conditions have in common is that they cause a “predominance of inflammation,” he adds.
To combat inflammation, follow these 5 principles of integrative medicine, he says:
Use food as medicine: Much of our medication, from aspirin to chemotherapy, has been derived from leafy plants, so it makes sense to use them in cooking. Green tea, turmeric and cinnamon have anti-inflammatory properties.
Use food to strengthen your immune system: The Mediterranean Diet is anti-inflammatory because it features a largely plant-based diet that focuses on vegetables, nuts and seeds, cold-water fish and healthy herbs and spices.
Get a good night’s sleep: During REM sleep, the body’s temperature dips slightly (about 1 ½ degrees) creating a cooling effect that helps reduce inflammation. If you have trouble sleeping, check your caffeine intake and turn of “screens,” in your room that can disrupt your melatonin levels. (Melatonin is the “sleep” hormone). This means TV’s, tables, and smart phones. Aromatherapy, the use of essential oils, can also create a restful environment.
Consider cxercise as medicine: A sedentary lifestyle impairs circulation over time, contributing to physical deconditioning that gives rise to obesity and osteoporosis and also increases the risk of high blood pressure and diabetes.
Practice meditation. A daily period of meditation has been found to strengthen the mind-body connection.
El Paso TX. Chiropractor Dr. Alex Jimenez takes a look at medication for joint pain and how they can make the pain worse.
Non-steroidal anti-inflammatory drugs (NSAIDs) are as common as candy, a staple of every home medicine cabinet and tossed casually in desk drawers, purses, and briefcases. Many people take these drugs, which include ibuprofen (sold as Motrin and Advil), naproxen (Aleve), and aspirin, at the first sign of a�headache or muscle cramps � and they are a daily ritual for many people living with arthritis.
But few people realize that NSAIDs carry a black-box warning, the strictest warning issued by the Food and Drug Administration. �Most people think that the government or FDA would not allow something dangerous on the market, especially since most of them are over-the-counter and [used] without a prescription,� says integrative medicine expert Sunil Pai, MD, author of An Inflammation Nation. �A black-box warning is the FDA�s attempt to let you know that you can end up in a casket if you are unlucky enough to suffer one of a medication�s serious reactions.�
Not only have NSAIDs been linked to a slew of serious side effects, including ulcers, hearing loss, allergic reactions and miscarriages, but they can actually worsen some of the conditions, such as arthritis, they are supposed to help.
�The scientific literature makes it abundantly clear that NSAIDs�have a significant negative effect on cartilage,� which accelerates the deterioration of arthritic joints, says Pai. �NSAIDs have no beneficial effect on [cartilage] and speed up the very disease for which they are most used and prescribed.�
Even worse, NSAIDs do not address the underlying conditions that cause pain and inflammation, such as a leaky gut, and can even exacerbate them. Stress, infections, alcohol, and a poor diet can all irritate the gut lining and lead to a leaky gut, but so can NSAIDs.
�If you use a full therapeutic dose of NSAIDs for two weeks, there is a 75 percent chance you will develop a leaky gut that doesn�t go away when you stop taking the drug, Leo Galland, MD, tellsExperience Life magazine.
6 Simple Dietary Interventions To Fight &�Heal A Leaky Gut
So, how can people with acute or chronic inflammatory conditions fight pain naturally? Some simple dietary interventions go a long way towards fighting inflammation and healing a leaky gut.
1. Try an Elimination Diet
Removing common foods that can irritate the gut, including gluten, sugar, dairy, processed foods and soy, can jumpstart the healing process. Sugar (and refined grains, which turn to sugar in the body), for example, is one of the single biggest drivers of inflammation and its downstream consequences.
When sugar cravings strike, try roasting root vegetables or sweet potatoes. Roasting concentrates the natural sweetness of the plant, but the fiber slows down sugar absorption in the bloodstream.
2. Eat Whole Foods
Michael Pollen�s recommendation � �Eat food. Not too much. Mostly plants.� � Is great advice when it comes to naturally fighting inflammation. Eating a Standard American Diet (SAD) � high in processed foods, unhealthy fats, and sugars � is like pouring kerosene on inflammation�s fire. Eating whole foods, rich in phytonutrients, helps put out that fire.
One fun way to eat more plants? Strive to �eat the rainbow,� or get at least one whole food from all the different colors of the rainbow each day:
Animal protein doesn�t need to be avoided if it�s grass-fed and pastured. Instead, try to reverse the ratio on your dinner plate: Make meat the side dish and vegetables the main course.
3. Supplement with Glutamine
Glutamine helps heal your gut by fueling the cells in your gut lining. You could think of it as a leaky gut superhero. �Glutamine heals the intestinal lining more than any other nutrient,� Liz Lipski, Ph.D., CCN, author of Digestive Wellness, tells Experience Life.
4. Get Your Omega-3s
Omega-3 fatty acids are natural inflammation fighters. Good whole food sources of omega-3s include wild-caught fish, grass-fed meat, pastured eggs, algae, and seeds such as hemp, chia, and flax. A high-quality omega-3 supplement is also worth considering. Even on a largely whole-foods-based, it can be hard to get the recommended daily amount of omega-3s.
5. Drink Bone Broth
Bone broth is one of the best natural sources of collagen, a protein found in abundance in our ligaments, tendons, bones, and skin. The collagen in broth is easily absorbed by our tissues and can not only help promote healthier connective tissue and ease joint pain, but it can also help heal a leaky gut. The best bone broth is homemade�but increasingly high-quality bone broth is available for purchase at cooperatives and health food stores.
6. Consider Botanical First Aid
Many plants are powerful inflammation fighters. Turmeric may be the best known and most studied.�Recent research suggests that the active ingredient in turmeric (called curcumin) has anti-inflammatory, antioxidant, antiviral, antibacterial, antifungal, and anticancer activities on par with commonly prescribed arthritis drugs like Enbrel and Humira.
A lot of other plants and plant compounds show similar activity in the body, including ginger, bromelain (an enzyme found in pineapple), capsaicin (the active ingredient in hot peppers), and ginger. Consult your healthcare practitioner before taking botanical supplements.
When you�re in pain, you might try just about anything to feel better. Claims of miracle cures that instantly relieve back and neck pain are tempting, but they often fall short of their promises.
Save your money and steer clear of the products featured promising to eliminate your spine-related pain.
Copper Bracelets
Copper bracelets and wristbands have attracted a following of arthritis sufferers because of their perceived ability to reduce joint pain.
The key word here is perceived.
A 2013 study in the UK examining the effects of copper bracelets in patients with rheumatoid arthritis found no difference in pain outcomes between those wearing copper bracelets and those using a placebo.
While the bracelets won�t do you any harm, they�re more for looks than clinical benefit. There�s no solid medical evidence available proving they reduce pain or inflammation.
Magnets
From magnetic shoe inserts to bandages, magnets have been heavily marketed as a miracle cure to zap away a variety of back pain conditions, including fibromyalgia and arthritis. However, no proof exists to back up magnets� health claims.
While studies have examined magnets� impact on pain, the results are mixed�and the quality of some of the research is questionable. Additionally, magnets are not safe for some people, including those who use pacemakers or insulin pumps.
Colloidal Silver
Silver jewelry? Classic. Silver home furnishings? Sure thing. Colloidal silver for your spine pain? Never a good idea.
Colloidal silver for back pain is typically found as a topical cream containing small particles of silver. In 1999, the U.S. Food and Drug Administration (FDA) recommended that people not use colloidal silver to treat any medical condition because it�s neither safe nor effective.
Even worse than the false claims of back and neck pain relief are colloidal silver�s strange and serious side effects. This product can interfere with the absorption of some prescription drugs and even permanently tint your skin a blue-gray color.
DMSO and MSM Dietary Supplements
If you have spondylosis (osteoarthritis), you may have heard of the dietary supplements dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM). Some believe this pair of supplements can block pain and inflammation, but no real medical evidence shows these substances actually relieve painful arthritis symptoms.
Instead of eliminating your arthritis pain, MSM and DMSO might cause some unwanted side effects. Both have been linked to causing upset stomach and skin rashes, while DMSO may also leave you with garlic breath and body odor.
A Word on Drug-Supplement Interactions
Speaking of supplements, it�s important to understand that dietary supplements may not mix with over-the-counter or prescription drugs. Some interactions result in mild side effects, but others can be much more serious�even life-threatening.
If you�re using a dietary supplement�even if it�s a seemingly benign herbal or vitamin�always let your doctor and pharmacist know before taking it with an over-the-counter or prescription medication. They will share any dangerous interactions, and ensure you�re safely addressing your back and neck pain.
The Real Deals: Alternative Treatments that Work
Many who fall prey to the products listed in this slideshow have an interest in alternative or complementary therapies for back and neck pain. While some non-traditional treatments should be avoided, many have been proven to reduce spine pain.
Scientists from the National Center for Complementary and Integrative Health at the National Institutes of Health reviewed 105 U.S.-based trials from the past 50 years that included more than 16,000 participants. They found the therapies below effective at controlling pain:
� Acupuncture � Massage � Relaxation techniques � Tai chi
If you prefer alternative methods to manage for your spinal condition, explore the therapies above. They are effective, safe, and will help you live a healthier life.
More Americans are looking beyond Western medicine to help relieve their back, neck, and spinal joint pain, including osteoarthritis of the backbone. In this specific article, we discuss Complementary and Alternative Medicine (CAM), which is also called Complementary and Integrative Medicine.
Interchangeable Terms
When an option (not mainstream) practice is combined with standard (mainstream) medicine, it�s called �complemental� or �integrative� health care. It�s called �alternative.� when it�s used in place of traditional medicine Nevertheless, these terms are frequently used interchangeably.
Complementary Alternative/Integrative Treatments
Although treatments might be combined you will find five general types of CAM therapies.
1. Alternative Medical Systems
Naturopathic or naturopathy medical care may include water therapy, massage, and herbal drugs.
2. Head-Body Techniques
Head-body techniques may help a patient with back or neck pain to utilize their head to change or restrain their symptoms in a way that is positive, therefore reducing pain.
3. Biologically-Based Therapies
Biologically-based treatments feature nature-based substances such as botanicals and dietary supplements to ease pain. Natural substances contain ginseng, ginkgo, fish oil, or Echinacea and could be obtainable in different kinds, including a tea, aromatherapy oils, syrup, powder, pill, or capsule.
4. Body-Based Practices
Body-established practices include different types of massage, body alignment techniques, osteopathic manipulation and chiropractic.
5. Energy Therapies
Energy therapies unblock energy fields or may help shift. Qi gong (eg, breathing techniques), Reiki (eg, stress reduction/relaxation), and magnets are treatments based on transferring energy.
Is Alternative, Complementary Or Integrative Therapy Right For You?
To assist you decide, look at the next points.
If insurance coverage is essential to you, be sure to consult your health insurance provider before you select a CAM treatment to make certain the professional is insured.
Learn as much as you can about the alternate treatment you’re enthusiastic about.
Take into account that although a complementary alternative treatment may be popular, that doesn�t make it correct for you personally.
Unlike mainstream medical care and procedures, some (if not most) alternative therapies are not scientifically validated by clinical trials and/or research studies. The amount of human players is frequently little, while there may be studies supporting a particular practice.
Simply because a material is natural doesn�t mean it can�t damage you, cause illness or allergic reaction, or a serious interaction with a drug. For instance, blood pressure can be raised by ginseng.
Always tell your treating physician about all of the herbs, vitamins and nutritional supplements (in any kind) that you take, particularly if you’re scheduled to get a neck or back process (eg, spinal injection, operation).
Select your alternative therapy professional with all precisely the same attention and concern you would for pain management specialist or a back surgery.
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Sources:
Rosenzweig S. Overview of Complementary and Alternative Medicine. Merck Manual. Consumer Version.� www.merckmanuals.com/home/special-subjects/complementary-and-alternative-medicine-cam/overview-of-complementary-and-alternative-medicine.
National Center for Complementary and Integrative Health (NCCIH). Complementary, Alternative, or Integrative Health: What�s In a Name? March 2015. nccih.nih.gov/health/integrative-health.
The practice of yoga coupled with deep breathing eased the symptoms of individuals suffering from depression without the use of potentially harmful medication, according to a recent study published in the Journal of Alternative and Complementary Medicine.
Major depressive disorder or MMD, or depression, is a common mood disorder causing sadness and serious mental health issues. Depression affects about 16 million Americans each year, according to the Centers for Disease Control and Prevention.
Researchers from Boston University Medical Center who conducted the latest study concluded that twice weekly yoga classes in addition to home practice helped brighten the mood of participants not taking antidepressants and for those who claimed their medication wasn�t working.
Since antidepressants come with common side effects such as nausea and insomnia, experts say that this new study offers an exciting and safe alternative treatment to the treatment of this common disorder.
Dr. Delia Chiaramonte, director of education, at the Center for Integrative Medicine at the University of Maryland School of Medicine, tells Newsmax Health that this new study solidifies the research that�s already been done examining the benefits of yoga not only for the body, but for the mind as well.
�There are multiple studies that suggest the benefits of yoga in people suffering from depression,� she says. �Exercise has also shown to have significant benefit in alleviating depression as well as meditative practices. Since the practice of yoga combines both physical exercise and meditation, in my opinion, it should be considered as an adjunct treatment for depression.
�It can be used alongside other forms of exercise, cognitive strategies, meditation, guided imagery and in severe cases, antidepressant medication.�
While the participants in the Boston University study practiced two to three 90 minute sessions of Iyengar yoga along with their home practice, experts say that a few minutes of daily practice can produce powerful results.
Iyengar yoga is a style that incorporates precise movements and alignments to balance the body and mind. Kundalini yoga, on the other hand, works on the energy systems of the body and can create equanimity in minutes to help battle depression, says Dr. Gregg Biegel, a certified Kundalini instructor, so you get more bang for your buck.
�People who are diagnosed with depression are almost always prescribed either short term or long term medication to combat their symptoms. But the harmful side effects of these drugs can sometimes make those symptoms worse,� he tells Newsmax Health.
�That�s like putting a Band-Aid on a severed artery. Scientists are now exploring alternative approaches to a healthier lifestyle without medication, and yoga, an ancient art that�s enjoying quite a revival in this stressful society, is a valuable tool.
�Human beings are complex emotional animals. Our behavior is directly controlled by the central nervous system, the autonomic nervous system and our glandular system. When these control systems are out of balance, you experience a wide range of emotions from nervousness to anger to anxiety and depression.�
The practice of yoga, says the expert, can help regulate and balance the body�s control systems by incorporating breathe and movement.
�Within minutes of practicing these physiologically powerful series of movements we call kriyas we can banish the blues and stave off depression,� he says.
While Kundalini yoga is considered to be the �fast track� to establishing equanimity between body and mind, it is important to study with a certified teacher, says Biegel. Since there as many styles of yoga as there are flavors of ice cream, find a class that suits your needs and preferences.
�Practicing yoga on a regular basis combined with eating a healthy diet and enjoying a positive lifestyle provides a natural alternative to medication in battling depression,� says Biegel.
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