Discover and read the best of Twitter Threads about #arthritis
Most recents (24)
Back to basics‼️
A tweetorial on a clinical approach to #joint #pain 🪡
1/n
The 🔠ABCDE approach
🅰️ Articular (or not!) 🦴
🅱️ Background (& burden) 🎒
C Chronology 🕰️
D Distribution 📍
E Extra-articular 🍂
Let’s dive deeper
#MedTwitter
#RheumTwitter
A tweetorial on a clinical approach to #joint #pain 🪡
1/n
The 🔠ABCDE approach
🅰️ Articular (or not!) 🦴
🅱️ Background (& burden) 🎒
C Chronology 🕰️
D Distribution 📍
E Extra-articular 🍂
Let’s dive deeper
#MedTwitter
#RheumTwitter
2/n
#Pain is #inflammatory if worst in the AM/ after rest
#Swelling which is not bony #Synovitis the sine qua non of #inflammatory #arthrits
#Stiffness esp in AM & > 1 hour
“How do you feel when you wake in the morning?”
is a great question to ask
#MedTwitter
#RheumTwitter
#Pain is #inflammatory if worst in the AM/ after rest
#Swelling which is not bony #Synovitis the sine qua non of #inflammatory #arthrits
#Stiffness esp in AM & > 1 hour
“How do you feel when you wake in the morning?”
is a great question to ask
#MedTwitter
#RheumTwitter
3/n
🅱️ = BACKGROUND
Age 🕰️
Gender ♈️♎️
Race 🧕🏻
#Comorbidities
Pregnancy🤱🏻
And 🅱️ = Burden👩🏻🦼
#impact of disease
#MedTwitter
#RheumTwitter
🅱️ = BACKGROUND
Age 🕰️
Gender ♈️♎️
Race 🧕🏻
#Comorbidities
Pregnancy🤱🏻
And 🅱️ = Burden👩🏻🦼
#impact of disease
#MedTwitter
#RheumTwitter
😣Patient: "All my joints are painful & swollen!"😣
👩⚕️But when you examine the patient, you don't find any joint swelling
How to approach this scenario? 🤷
#MedTwitter #RheumTwitter #MedEd 🧵🧵🧵
(1/10)
👩⚕️But when you examine the patient, you don't find any joint swelling
How to approach this scenario? 🤷
#MedTwitter #RheumTwitter #MedEd 🧵🧵🧵
(1/10)
Now there are two possibilities
1️⃣ There was a joint swelling which is no longer there
OR
2️⃣ There was no joint swelling to begin with
(2/10)
1️⃣ There was a joint swelling which is no longer there
OR
2️⃣ There was no joint swelling to begin with
(2/10)
Let's start with the first one– there was indeed joint swelling which is no longer there
That means we are dealing with
☝️ An episodic inflammatory disease
✌️ Drug modified disease
(3/10)
That means we are dealing with
☝️ An episodic inflammatory disease
✌️ Drug modified disease
(3/10)
Emulsifiers! You unknowingly consume them daily. They are in almost every readymade food. But what are these and what impact they have on your #health. In below thread, i explore the world of #emulsifiers and why you should avoid them. #HealthyLiving #weightloss #processedfood
Emulsifiers are detergent that combine different substances together. Certain substances in food are water soluble & others are fat soluble. How to mix them together? Add emulsifiers & voila - problem solved
The emulsifiers mostly have names that is difficult to pronounce but you can see them in food ingredients list on packaging. Common ones are polysorbate 20, 60 or 80 (P80), carboxymethyl cellulose (CMC), sorbitran, propylene glycol, sodium stearoyl lactylate, Gum arabic
Believers that #LongCovid is "all in your mind" because there are on specific biomarkers or routine diagnostic tests are "normal" need to look at other autoimmune/inflammatory disorders. In #MultipleSclerosis, or example, it took decades to refine the diagnostic criteria. 1/🧵
First, before MRI/CT scans were invented, many #MS pts were misdiagnosed with psych disorders, including hysteria. Spinal taps in MS patients did not always reveal abnormalities. Many patients had various non-specific white matter lesions in MRI, but some had few or none. 2/🧵
Some #MS pts had optic neuritis, but many did not. Some had a lesion in the cervical cord, and many did not. How do you make sense of it all? It took many years and several revisions to come with the diagnostic criteria that we use today to diagnose MS and MS variants. 3/🧵
#Methotrexate is the nr1⃣drug of choice for Rheumatoid #Arthritis.
MTX's history is eventful, and deserves a 🧵
🔹It started with childhood leukeamia
🔹Sleeping Beauty in the 1960-70's
🔹Awakened by Hoffmeister
🔹FDA👍1988 and 🔝 in the 1990's
1/🧵 #RheumTwitter #MedTwitter
MTX's history is eventful, and deserves a 🧵
🔹It started with childhood leukeamia
🔹Sleeping Beauty in the 1960-70's
🔹Awakened by Hoffmeister
🔹FDA👍1988 and 🔝 in the 1990's
1/🧵 #RheumTwitter #MedTwitter
The start:
🔹1948, Dr Farber treated 5 children with #leukemia with Aminopterin, an anti-folate & precursor of #MTX, with outstanding results
🔹1951, first positive results of Aminopterin in #RA & #Psoriasis pts
Despite this, Aminopterin was aborted in RA
2/🧵 #RheumTwitter
🔹1948, Dr Farber treated 5 children with #leukemia with Aminopterin, an anti-folate & precursor of #MTX, with outstanding results
🔹1951, first positive results of Aminopterin in #RA & #Psoriasis pts
Despite this, Aminopterin was aborted in RA
2/🧵 #RheumTwitter
MTX enters:
Due to difficulties in manufacturing, Aminopterin was modified and MTX was created.
🔹1962, positive results with MTX in both RA and #PSA
🔹Next 10 years: MTX was extensively studied in #psoriasis but halted in #RA
🔹In RA, MTX becomes the Sleeping Beauty👸💤
3/🧵
Due to difficulties in manufacturing, Aminopterin was modified and MTX was created.
🔹1962, positive results with MTX in both RA and #PSA
🔹Next 10 years: MTX was extensively studied in #psoriasis but halted in #RA
🔹In RA, MTX becomes the Sleeping Beauty👸💤
3/🧵
(1/8) நீங்கள் அதிக எடை அல்லது பருமனாக இருக்கும் ஒவ்வொரு கிலோவிற்கும், நீங்கள் நடக்கும்போதும், ஓடும்போதும் அல்லது படிக்கட்டுகளில் ஏறும்போதும் உங்கள் முழங்கால் கூடுதலாக 4 கிலோ அழுத்தத்தை உள்வாங்குகிறது.
#KneePain #Arthritis #கீல்வாதம் #DrMaran #SpringfieldWellnessCentre
#KneePain #Arthritis #கீல்வாதம் #DrMaran #SpringfieldWellnessCentre
(2/8) எனவே முழங்கால் வலியை விட உடல் எடையின் முக்கியத்துவத்தை இது குறிக்கும் விதமாக இருக்க வேண்டும். அதனால்தான் நமக்கு ஏற்ற உடல் எடையை பராமரிப்பது முக்கியமான ஒரு விஷயமாகும்.
#Bariatric #KneePain #Arthritis #கீல்வாதம் #DrMaran #SpringfieldWellnessCentre
#Bariatric #KneePain #Arthritis #கீல்வாதம் #DrMaran #SpringfieldWellnessCentre
(3/8) மேலும் அதிக எடை அல்லது பருமனாக இருந்தால், உடல் எடையை குறைப்பது முழங்கால் கீல்வாதம் எனப்படும் ஆர்த்ரைட்டிசின் வளர்ச்சியைக் குறைக்க கணிசமாக பங்களிக்கும்.
#Bariatric #KneePain #Arthritis #கீல்வாதம் #DrMaran #SpringfieldWellnessCentre
#Bariatric #KneePain #Arthritis #கீல்வாதம் #DrMaran #SpringfieldWellnessCentre
💭When we think of #Rheumatoid #Arthritis , a mental image of this comes up 👇
But does it have to get to this🤔???
🙅NO! Definitely, NO! 🙅
#MedTwitter #MedEd #RheumTwitter #Rheumatology
@MedTweetorials
(1/8)
But does it have to get to this🤔???
🙅NO! Definitely, NO! 🙅
#MedTwitter #MedEd #RheumTwitter #Rheumatology
@MedTweetorials
(1/8)
🪜The first step is early diagnosis, do not wait until the deformities to form!
💬Think of RA when a patient presents with
🔸Peripheral
🔸Symmetric
🔸Arthritis
🔸Morning stiffness>30 minutes
#MedTwitter
(2/8)
💬Think of RA when a patient presents with
🔸Peripheral
🔸Symmetric
🔸Arthritis
🔸Morning stiffness>30 minutes
#MedTwitter
(2/8)
🧪👨🔬A positive Rheumatoid factor is seen in ~70% of cases and anti-CCP in ~75% cases, so about 1/5th of the cases may be seronegative!!
So a good history and clinical examination is the king 👑
(3/8)
So a good history and clinical examination is the king 👑
(3/8)
Less Than 6 Hours of #sleep a Night Linked to Serious, Chronic Illness
1. Beginning at age 50, those who slept 5 hours or less a night had a 30% higher risk of developing multiple chronic diseases over time than those who slept at least 7 hours a night.
#MedTwitter #MedEd
1. Beginning at age 50, those who slept 5 hours or less a night had a 30% higher risk of developing multiple chronic diseases over time than those who slept at least 7 hours a night.
#MedTwitter #MedEd
2. By the time the participants were aged 70 years, that risk had increased to 40%.
3. Higher risk was seen for #diabetes, #Cancer, heart disease, #stroke, COPD, chronic kidney disease, #liver disease, #depression, #dementia, #Parkinsonsdisease, and #arthritis.
3. Higher risk was seen for #diabetes, #Cancer, heart disease, #stroke, COPD, chronic kidney disease, #liver disease, #depression, #dementia, #Parkinsonsdisease, and #arthritis.
Conclusion: It is important to get 7-9 hours of good quality sleep to reduce the risk of many chronic diseases.
(Ref: Less Than 6 Hours of Sleep a Night Linked to Serious, Chronic Illness - Medscape - Oct 21, 2022).
(Ref: Less Than 6 Hours of Sleep a Night Linked to Serious, Chronic Illness - Medscape - Oct 21, 2022).
INFLAMMATORY ARTHRITIS
it's a word we throw around a lot
What does it mean? How can you tell the different causes from one another?
a🧵
#meded #rheumatology #rheumtwitter #arthritis @VuMedi
it's a word we throw around a lot
What does it mean? How can you tell the different causes from one another?
a🧵
#meded #rheumatology #rheumtwitter #arthritis @VuMedi
Inflammatory arthritis just refers to:
🌟immune cell (typically innate) invading the joint space
🌟 typically neutrophils are the 1st to the scene of the crime
🌟immune cell (typically innate) invading the joint space
🌟 typically neutrophils are the 1st to the scene of the crime
Normal synovium has very few cells
if you tap a joint, and there is greater than 2,000 WBC, this is considered "inflammatory"
lots of things can do this:
🌟trauma-foreign body into a joint
🌟infection-septic joint
🌟crystals-gout or pseudogout
🌟autoimmune!
if you tap a joint, and there is greater than 2,000 WBC, this is considered "inflammatory"
lots of things can do this:
🌟trauma-foreign body into a joint
🌟infection-septic joint
🌟crystals-gout or pseudogout
🌟autoimmune!
A long thread 👇🏼:
I would like to share with you my latest review article. The Epstein-Barr virus (EBV) has long been known to be behind the development of autoimmune diseases, cancer and is even suspected to be behind the development of Chronic Fatigue Syndrome/… (1)
I would like to share with you my latest review article. The Epstein-Barr virus (EBV) has long been known to be behind the development of autoimmune diseases, cancer and is even suspected to be behind the development of Chronic Fatigue Syndrome/… (1)
…Myalgic Encephalomyelitis and Long COVID. But it is still unclear what pathways it uses.
In this review I describe how the possession of certain ancestral HLA-II alleles (a system used by our immune system to recognize which proteins are foreign,… (2)
In this review I describe how the possession of certain ancestral HLA-II alleles (a system used by our immune system to recognize which proteins are foreign,… (2)
…such as pathogens, and which are not) makes the individual genetically weak to control EBV latent cells, thus developing different diseases. EBV infects B cells through a protein on its surface called gp42, which allows it to bind to HLA-II molecules on the B cell surface. (3)
There is a lot of confusion about what #LymeDisease tests under the #CDC #twotier standard are actually designed to diagnose. I’d like to elucidate for all but am feeling kinda lazy, lol. Let’s see here. 1/x
Some think #lymeDisease diagnostics are geared toward #earlylyme only, while some say #latelyme or #LymeArthritis. It’s more specific than that & there is a reliance on timing & interpretation of results to exclude as many cases as possible. 2/x
First of all, one must understand that #LymeDisease & diagnostic test outcomes vary based on people’s genetic makeup, among other factors. People with certain HLAs (studied in-depth by #AllenSteere) tend to have a stronger immune response. 3/x
Epstein–Barr virus (EBV) is a human gamma herpesvirus. It is known to have infected and generally become latent in more than 90% of the global population [7], including more than 95% of healthy adults [8]. #EBV
ncbi.nlm.nih.gov/pmc/articles/P…
ncbi.nlm.nih.gov/pmc/articles/P…
"A variety of clinical manifestations have been associated with EBV reactivation. These include fatigue, psychoneurosis/brain fog, sleep disturbance, arthralgia, pharyngitis, myalgia, headaches, fever, gastrointestinal complaints, and various skin rashes." #EBV
"We found that 66.7% (20/30) of long-term long COVID subjects versus 10% (2/20) of long-term control subjects were positive for EBV reactivation based on positive titers for EBV EA-D IgG or EBV VCA IgM." #EBV / #LongCovid
1/ Just listened to @BBCWomansHour talking to ‘Carla & Brendan’ about living with #Fibromyalgia (find it at 35.25) thanks @fmauk for flagging, this is where I started & gradually more & more drugs were added until I was unrecognisable, 25 stone
bbc.co.uk/sounds/play/m0…
bbc.co.uk/sounds/play/m0…
2/ and living in my armchair, I never went out except for medical appointments & my wife @Trewern_K became my full-time carer which she did not begrudge for a second but it did limit her life too! The cocktail of drugs meant I couldn’t stay awake during the day, was awake at
3/ night & dozed off during video calls with my grandson 🥲 I was in crippling amounts of pain despite being on an EMD morphine dose of 320mg a day! We are all different but I believe coming off #opioids (UNDER MEDICAL SUPERVISION) literally saved my life!
Weekend Digest
Name the Pathogen
5 Clues:
- #Chitlins
- #Iron sepsis
- Mesenteric #adenitis
- Reactive #arthritis
- Terminal #ileitis
Name the Pathogen
5 Clues:
- #Chitlins
- #Iron sepsis
- Mesenteric #adenitis
- Reactive #arthritis
- Terminal #ileitis
2/
#Yersinia enterocolitica
It is #zoonotic and is acquired by exposure to contaminated food.
When #IDBR says #chitlins (#chitterlings), you say Y. enterocolitica
Chitlins are food made of pork intestines (where Y enterocolitica resides)
ncbi.nlm.nih.gov/pmc/articles/P…
#Yersinia enterocolitica
It is #zoonotic and is acquired by exposure to contaminated food.
When #IDBR says #chitlins (#chitterlings), you say Y. enterocolitica
Chitlins are food made of pork intestines (where Y enterocolitica resides)
ncbi.nlm.nih.gov/pmc/articles/P…
3/
#Yersinia enterocolitica
Enterobacteriaceae #GNB that causes #enterocolitis, diarrhea (often bloody), terminal #ileitis, mesenteric #adenitis, and RLQ pain that may be mistaken as #appendicitis (#pseudoappendicitis)
#Yersinia enterocolitica
Enterobacteriaceae #GNB that causes #enterocolitis, diarrhea (often bloody), terminal #ileitis, mesenteric #adenitis, and RLQ pain that may be mistaken as #appendicitis (#pseudoappendicitis)
1) World With Complex Regional Pain Syndrome
(CRPS) As My Constant Companion
I live in a world with Complex Regional Pain Syndrome (CRPS) as my constant companion. Physicians don’t know why it develops, but #CRPS is a nerve disorder that
(CRPS) As My Constant Companion
I live in a world with Complex Regional Pain Syndrome (CRPS) as my constant companion. Physicians don’t know why it develops, but #CRPS is a nerve disorder that
2)usually occurs after a traumatic injury, surgery, sprain, fracture, infection or a period of immobilization. CRPS/RSD is said to be the most painful chronic disease that’s known today. On the McGill #Pain Index it (Causalgia) scores 42 out of 50.
3)How does that compare to other types of pain and/or chronic pain conditions? #Arthritis pain is ranked about 18, Non-terminal Cancer pain at 24 and Chronic Back Pain is at 26. Natural labor and delivery of a 1st child is about 35. With a score of 40, the pain associated
#Friday #fridaymood #weekend Kratom Red 🐉 Dragon Powder
krakenkratom.com/buy-red-dragon…
#Reddragonkratom #kratom #kratomreddragon
Kratom Red Dragon helps one feel more serene, tranquil and calm. Its soothing effect also helps you feel as if the remainders of your senses are enhanced.
krakenkratom.com/buy-red-dragon…
#Reddragonkratom #kratom #kratomreddragon
Kratom Red Dragon helps one feel more serene, tranquil and calm. Its soothing effect also helps you feel as if the remainders of your senses are enhanced.
THREAD: Trama-DO or Trama-DON'T?
What to know about #tramadol
1/7 Tramadol has multiple mechanisms of action:
- via serotonin & norepinephrine reuptake inhibition
- after metabolism to M1 metabolite, via opioid agonism
bit.ly/3t5o7jC #chronicpain #arthritis #MedEd
What to know about #tramadol
1/7 Tramadol has multiple mechanisms of action:
- via serotonin & norepinephrine reuptake inhibition
- after metabolism to M1 metabolite, via opioid agonism
bit.ly/3t5o7jC #chronicpain #arthritis #MedEd
2/7 People metabolize #tramadol variably 🤔💊
- Some who are ‘ultra rapid’ produce more M1 (opioid);
- Some ‘poor’ metabolizers (~20% with inactive CYP2D6) may have more SSRI/SNRI-like effect
Thus, analgesic & adverse effects are unpredictable
ncbi.nlm.nih.gov/books/NBK315950 #MedEd
- Some who are ‘ultra rapid’ produce more M1 (opioid);
- Some ‘poor’ metabolizers (~20% with inactive CYP2D6) may have more SSRI/SNRI-like effect
Thus, analgesic & adverse effects are unpredictable
ncbi.nlm.nih.gov/books/NBK315950 #MedEd
3/7 Tramadol, once called a ‘safer’ opioid, causes tolerance and withdrawal, and is associated with addiction, overdose, and death
Observational studies show people treated with #tramadol, vs other opioids, are ↗️ likely to engage in prolonged opiate use #chronicpain #arthritis
Observational studies show people treated with #tramadol, vs other opioids, are ↗️ likely to engage in prolonged opiate use #chronicpain #arthritis
Thank you to @BethDarnall for speaking at #Minnesota @MinnesotaDHS #Opioid Work Group mtg on Thursday: Spoke of importance of #patientcenteredcare, #patientconsent necessary if taper & strongly advised AGAINST force tapers & using pre-determined MME'S. #ChronicPain #NoOneSize
MN #opioid Work Group created Taper Guidance. It will be out 4 public comment soon. Some areas extremely problematic. Although it states NOT 2 taper solely 2 meet system or state policy; MN Quality Improvement requires Drs 2 meet MME thresholds = TAPER TO MEET STATE POLICY. 🤔
If #ChronicPain pt wants 2 try 2 taper from #opioid analgesics 4 any reason & CONSENTS, there needs 2 be safe way 2 do it. Problem throughout U.S, incl #Minnesota; is non-consensual tapering. Many experts, incl #addiction specialists, stress dangers & even state it's UNETHICAL.
My @dogs4EU, like all of us are getting old. They need medicines for debilitating conditions of old age. #arthritis #Pain #epilepsy drugs. Yesterday, I found that my vet couldn’t find my Bonnie’s medicine. Eventually, found a new supplier which cost me £15 more. #AnimalWelfare
My @dogs4EU are my family. @SODEMAction @No10Vigil @wooferendum knows them. They were by my side. Now they are frail, I won’t let them suffer. But what if medicines run out? Are pet owners and farmers aware that #NoDealMeansNoMeds due to customs delays. #Brexit raised cost.
How many pets will suffer, be abandoned or even put to sleep as owners can’t/won’t buy their life saving medicines? My vet is very upset. Double whammy of #COVID__19 and No Deal will cause millions of #animals to die! Avoidable deaths of innocents! @DogsTrust is aware. Are you???
Patients with autoimmune diseases, such as #lupus and #RheumatoidArthritis, are having trouble filling their prescriptions since Trump touted their medicine as an experimental treatment for #Covid19. /thread news-journalonline.com/news/20200405/…
“The hasty and inappropriate interpretation of the literature by public leaders has potential to do serious harm" write 2 rheumatology experts in the Annals of Internal Medicine. annals.org/aim/fullarticl…
FL pharmacists report "nearly all of the new prescriptions for #hydroxychloroquine are being issued for the prescribing practitioners themselves or family members of the prescribing practitioners." Some drs are prescribing it to healthy people as a #Covid19 preventative.
Donald J. Trump's misinformation campaign contd in today's presser, jeopardizing lives in the process. I wish I had counted how many times he recklessly played Dr. today, prescribing Rx cocktails for people against COVID-19, asking "What do you have to lose?" Really? Their lives!
Further, many of those living with #Lupus are already struggling to access the meds they need to remain healthy & alive due to reckless guidance he previously offered. Can someone please mute his mic or just limit the Q&A to Fauci? This is criminal, all of it!
Those with rheumatoid #arthritis too. The last time Trump asked the American people, Black folx in particular, "What do you have to lose?" We know how that went. We are living the dire & draconian answer by the hour.
Our foundation needs your input. I am writing about Microdrop's "imaware" home #celiac test and #rheumatoid #arthritis tests. Reply, DM or send an email to me at jiscol@celiaccommunity with your experience. Your name will not be published without your permission. RTs helpful.
We would like to hear about your Microdrop @imaware_health #celiac or #rheumatoid #arthritis test experience, positive or negative, whether adults or children were tested, whether you acted on the results, whether you looked into it and haven't purchased one, etc.
If you used an @imaware_health home #celiac or #rheumatoid #arthritis test in LATE APRIL, MAY or JUNE, we have an extra interest in hearing from you.
If you are an influencer paid to promote the company or received a free test, please disclose.
Qs are welcome - thanks!
If you are an influencer paid to promote the company or received a free test, please disclose.
Qs are welcome - thanks!
OK #hospmed19, I had told myself I wasn't going to make another #tweetorial until next week to give myself a break, but I can't help but be motivated by all the amazing #tweeps at this meeting. Long story short, here's a #medthread on #PSORIASIS!
#MedEd #FOAMed PC:@dermnetnz
1/
#MedEd #FOAMed PC:@dermnetnz
1/
More and more, we are recognizing psoriasis to be a systemic disease. Aside from the psoriatic #arthritis we all know and love, there is more convincing evidence that psoriasis is linked with #cardiovascular disease and risk. As such, #multidisciplinary care is important!
2/
2/
There are many different variants of psoriasis. The most classic is plaque psoriasis, described commonly as "salmon colored plaques with micaceous scale."
Q: Ever notice how psoriasis doesn't really get impetiginized/superinfected but eczema does? Why do you think that is?
3/
Q: Ever notice how psoriasis doesn't really get impetiginized/superinfected but eczema does? Why do you think that is?
3/
5 Life-Enhancing Benefits of Strength Training for Adults Over 55 🏋🏽♀️
Strength training and regular aerobic activity help prevent many chronic and degenerative diseases related to #aging.
Here are 5 #health benefits that strength training can provide to older adults...
1/7
Strength training and regular aerobic activity help prevent many chronic and degenerative diseases related to #aging.
Here are 5 #health benefits that strength training can provide to older adults...
1/7
1. Stronger Muscles
Stronger muscles protect the joints of the body. Muscle weakness can cause the hips, spine, and shoulder to be less stable and more prone to injury.
A stronger body can withstand the #stress of daily activities.
#strengthtraining
Stronger muscles protect the joints of the body. Muscle weakness can cause the hips, spine, and shoulder to be less stable and more prone to injury.
A stronger body can withstand the #stress of daily activities.
#strengthtraining
2. Chronic Pain Relief
Many #chronicpain issues are a result of muscle weakness and muscle imbalances.
Strength exercises can correct these imbalances to restore the function and integrity of the joints.
Many #chronicpain issues are a result of muscle weakness and muscle imbalances.
Strength exercises can correct these imbalances to restore the function and integrity of the joints.
