Back Pain Questions Archive 2009 Part 8

Comment: I have suffered from neck and back problems regularly for two years now. I have tried chiropractors, osteopaths, physiotherapists and now Acupuncture. I have recently had an ultrasound which said I have impingement of the shoulder. I believe the pain is coming from my neck and radiating into my left shoulder and down my arm. I am almost in tears daily and no one seems to understand the pain I am enduring each day. This is affecting my quality of life and my work. I am so frustrated and don't know what to do... Acupuncture seems to have made my problem worse. Paulette

Q: Hello, In 1999 I injured my back at work and had a microdiscectomy of levels L3-L4. I recovered well with very little residual pain.Then in 2005 I injured my back at L5-S1. I had a microdiscectomy at that level and recovered well. I was left with a little pain but was able to live with it.In 2007 I injured my back at levels L3-L4 and L4-L5. I underwent a double microdiscectomy and again recovered OK an was able to work.In 2009 I injured my back once again at levels L3-L4 and L4-L5. I was also told that I had degenerative disc disease. This time I had a double discectomy and spinal fusion.I have recovered well enough to be released to work but, everyday the pain from the surgery gets worse. The longer I work I get pain radiating down my right leg and I have stabbing sensations where the hardware was installed.The pain radiates into both buttocks and I have constant pain in my lower back although it is a dull pain. I fear that if I continue to work I will become severley disabled but I cannot stop working to apply for disability. I suppose I will have to live with this pain for the rest of my life and hope that I don't injure myself again. Les

Q: My name is Maha. I'm 46 years old. I'm a lecturer of Embryology. I've been experiencing cervical pain 20 years ago or even more. I experienced several types of conservative treatments as physiotherapy, collar, muscle relaxants, pain killers,...2o years ago I was told by my physician after reviewing my x-ray that my neck muscle is so weak it's like a thread.He asked me not to carry anything heavy even a plate of rice. Since then I was so cautious about carrying extra weights or exposed to cold weather and more. Now the pain is getting worse despite the precautions. It is chronic, meaning I am always at pain the 24 hours. I can't sleep except on a very hard pillow or even a hard text book. I sometimes have some numbness and mild pain at my left hand.A month ago I fall down on my back so I was asked to perform an X-ray on my column. The report was:Dorso-Lumbar Spine revealed:

-Scoliosis of the upper lumbar spine with convex to the left side.

-Spondylotic changes of the dorso-lumbar spine are noted showing marginal end plate osteophytic lipping.

I was then asked to perform a MRI on my cervical vertebrae.MRI cervical findings:

- Normal dimensions of the cervical spinal canal.

- Cervical spondylodegenerative changes evident by anterior marginal osteophytic lipping of the vertebral endplates reduces bright T2 signal of the intervertebral discs, reduced height of C4/5 down to C6/7 discs and subtle degenerative marrow changes.- C5/6, C6/7 and to a lesser extent C4/5 posterior disc bulges with traction osteophytes are seen effacing the anterior subarachnoid space without significant mass effect on the cord.

- Normal size and signal intensity of the cervical spinal cord.

- Normal cranio-cervical articulation.

- No paraspinal soft tissue lesions.

My questions are: Firstly, Do I have to do something with my dorso-lumbar vertebrae despite not feeling any pain at that region?Secondly, what is your opinion about my cervical MRI and how can I stop my continuous cervical pain ?

Q: I got in a minor car accident a year and a half ago when I was 20 years old. I did not experience back pain until about a week after the accident. The first week was all neck pain and migraines, which eventually went away. After my lower back pain got to the point where I knew something was wrong, I went back to the doctor. I did chiropractic for 4 months. I was feeling a little bit better, but I still had minor pain that was consistent. I went back to my doctor and she recommended physical therapy. I did physical therapy for 6 months, going twice a week. Again, it didn't help my back pain. After going back to the doctor, I got an MRI which showed a slightly bulged disc in my lower back. From there, I saw a specialist who recommended cortisone shots. I felt like I was at the end of my ropes, so I got the injections. He did them at 4 facet joints, assuring my pain would be gone in less than a week. In fact, this injection made my pain worse. When I went to the follow-up appointment, we rescheduled to get more injections around the disc that is bulged. I got the 2nd round of injections about a week ago, and I have never experienced this much pain in my lower back and hip. I can barely walk because the pain in my left hip and lower back. The specialist said if this didn't would we would have to try something else. Please give me some advice on where to go from here. I am sick of professionals "trying" to make the pain go away. I have been in pain for too long, and do not know what other options to look at at this point. Thanks for any advice you can give me. Emily

Q: I'm sorry to bother you but your site seems to be the only helpful site i have found so far.I'm looking for a particular feminine disease/affliction that causes back pain.However to my knowledge it is not a very common one and no one can seem to tell me what it is called.

A friend of mine has a 16 yr old daughter that is having really bad back issues and I thought about a story i read a little while ago.Sadly I cannot find the article nor anything directly related to it.It pretty much comes down to this,it is a uterus problem,something to do with swelling and the like that causes the uterus to put pressure on the back.If I remember correctly it is because the uterus is filled with liquid of some form and that is the cause of said back pain. However tests on my friend's daughters back are not providing any information and i think there might possibly be a link.

I hope you can help me i have spent so much time looking and I don't want to scare him by saying your daughter might have this if the symptoms don't match.And seeing as you seem to have back information i was wondering if you had run across anything like this on YOUNGER females in the teens.I realize this is probably not your area of expertise but if you have run across any possible ideas and/or information I would greatly appreciate your sharing it with me. Thank you, Jontai

Q: Hi, I have suffered from back pain my whole life and have been diagnosed with 3 herniated disk in my neck. Most of the time a chiro visit makes me feel better. However about 3 weeks ago my middle finger became numb and i had some chest muscle (rt side pec area)along with neck soreness. Now i have tingling down my right arm and spasm in every area surrounding the shoulder, neck, and under arm (lat area). when i massage it the area, it sends tingles down my rt arm. I have been icing my neck and back areas and taking advil. but it seems to be getting worse. My Chiro says it takes time for the nerve to calm down. i am afraid of doing damage. Please advisePS its worse in the morn and when i move into a certain position the tingling starts. the finger is always numb. Michele

Q: Sensei Rostocki, First, thank you for providing this forum for sharing information on back pain. I am a 52 yr old male and have been practicing martial arts for over 10 years. I also have had back problems for many years and now am considering another surgery. I first hurt my back in my mid twenties when did a high dive and hit so hard my heels touched my shoulders. At that time I had xrays and was told that I only pulled muscles in the injury.

Jump to my 30's I started having problems with sciatic pain in my R. leg when running but a chiropractor helped me get back on the road and I ran many 10K's, 10 milers and the Marine Corp Marathon in 85, 90 and 95. It was during training for the 2000 marathon that my back really blew out. I had surgery in Dec 98 for a badly ruptured disc at L5-S1. At that time I was told that L4-L5 was also bulging but not bad enough to be operated on.

I never made a full recovery after surgery though; I could run 5 miles but then the next day I'd have such pain I practically wouldn't be able to walk. I also had some numbness in the bubbling spring point on the bottom of my R foot. Now jump to 2006 when when I could tell I was heading downhill again. Before I could get in for an MRI, I had an acute incident with back pain and extreme sciatica in my r. leg which after 2 days developed into foot drop. I had to have "semi - emergency" surgery and they thought that L4-5 was the problem, but when the surgeons got in there, they found that disc still intact but also found 3 or so particles that apparently had migrated up from L5-S1 (that must have re-ruptured at some point and the fragments were calcifying and growing larger and lodging at the L5 facet until the sciatic nerve was completely impinged resulting in the foot drop.

I never regained reflexes in my R. ankle after that and the pain has only continued to increase since 06. This summer I had another acute flair-up and went for an MRI which shows that I have an acute HNP at L4-5 and inflamed nerve root at L5. In addition, I had a CT-myelogram that shows I have DDD and foraminal stenosis with two pinched nerve roots (L4 and L5?). One Dr. wanted to decompress the two nerves while another recommended that if I was to have surgery, I would need a two level fusion, but only after exhausting conservative treatments. I've had 3 epidural steroid shots of some sort this yr plus 7 physical therapy sessions with no lasting relief.

I'm about to see one of the leading neurosurgeons in the world, thanks to help from a martial artist friend who also was operated on by this Dr and who is now good friends with him. I'm just curious, if he says to have surgery would you think I should go for it? Giri, Scott

Q: sir in 2001 i just slip from the mud and hit my left back to wood and from there i directly went to hot spring to cure but it worked out. But after 6 years now my back pain is very terrible and i have done x ray and even ultra sound but doctor say all fine, but still my lower back affect all my joints and is giving more pain even to neck also. Also i feel headache because of the pain pain. At the same time I have done lots of physiotherapy also. so i would like to request your feedback and solution for my chronic back pain and further advice. Kuenga

Q: Hi.. I am an Apache pilot in the military currently deployed to Iraq. I have your exact condition with the two herniated discs at L4/L5 and L5/S1. It is causing severe sciatica. Have received MRI and CT scan showing herniations. Please let me know what to do to recover in just a few weeks. Physical therapist says i need to stretch the nerve with various stretches she showed me, which naturally inflames the nerve, but i understand that is necessary to centralize the pain back into the lumbar region and out of the leg. Is this accurate? Thanks for all your help! Blake

Q: hello, i was just reading all of the Q's and A's and i was looking for the answer to this question...Is it possible to fix the slipped vertebrae completely, to where the vertebrae lines up correctly? Sam

Q: Hello, I am a 35 year old female, good health and about 2 months ago I hurt my lower back one morning when I fell getting into the shower,. At first it bruised real bad, and I could hardly get around. Then after about 2 weeks it just got worse, had swelling in my lower back and severe pain that began to move down my buttocks into my legs, they stay numb and tingle alot, often with severe burning sensation, bad enough I sit and cry all the time, i went to Er and they done x-rays and said i pulled a muscle, but it's only getting worse and it has made me begin to limp, cant sit stand or lay for long lengths, also it has made my bladder seem weak, meaning i often leak on my self, I really think I have done severe damage, what do you think?? Towana

Q: Hi, I wrote a while back, I would like to say thank you, your book has made a world of difference and started me on the information journey of psychosomatics. I have a question I would like to have comfirmed please, The back pain has gone, but I have developed tinnitus and pain in the buttocks. Would I be correct in assuming its the pain syndrome just moving to still distract me? Have you heard of this before? Thank you for your time, Lee

Q: Dear Sir, My wife is suffering with back pain for the last one year.MRI AND X RAY does not show any significant aberrations.but she is feeling enormous pain while she is getting out from bed. moderate pain while walking and while sitting and standing.while i standing posture she is not experiencing the pain.no radiating pain in to the legs.Many doctors are not able to diagnose the problem.kindly advise. Choudary

Q: Hi, Just a quick note to say that this site saved my life. I was due to have surgery and then read your articles. I realized that my pain did not make sense from cervical disc disease adn I put off my fusion to try your approach. I am pain free now for months and feel great. My surgeon is stumped. Thanks so much and keep up the great work. Tina

Q: Have you heard of RF Neurotomy and if so what is your opinion on the procedure. From my understanding it is a procedure in which a number of nerves near the spine are cauterized/cut so that the ultimate effect is to break the "pain cycle" and stop chronic pain. Don

Q: Hi! I think this is a great thing you've got going on with your website. Back pain is something that affects a lot of people and definitely hinders sleeping habits including my own. I thought I would let you know of a major sales promotion opportunity for your viewers. Serta mattresses are doing a half off sale starting November 11th and going through the 21st only at Sears locations. Obviously there are a lot of ways you can help your back pain, but buying a nice new comfy mattress is definitely a good alternative, especially when it's 50% off. I just thought if you felt it was beneficial for your viewers to know about, you could include this somewhere in your site temporarily. If not, good luck with everything you're doing here -- I think it's great. Thanks so much and have a nice day. -Charlie

Q: dear sir my m.r.i says that i have arthritis in the spine. i have very little pain in the back, but i have to take pain killers most of the time. doctor has tried anti-inflammatory pills but did not work. my pain is in the buttocks front leg side and down my groin and into the top of my testicle. is there any other treatments? David

Q: I am suffering from shoulder back pain last one year. Kindly give me the suggestion to get ride of this pain. Please also give me the specialist name and address in DELHI. Hari

Q: I recently had a MRI done of my lower back. The MRI's results were 2 herniated disks and DDD. I also have an exaggerated curve/hunch in my upper back. The upper back is my main problem. My lower back pain is very frequent but goes away. I consulted a neurosurgeon about my pain. He told me to try physical therapy for the pain. He told me there is nothing you can do for the scheuermann's kyphosis. Our visit lasted 5 minutes. I took the physical therapy, didn't work! I am 27 yrs. old and am in a lot of pain. Is the decision for surgery mine to make? Or, does it have to be recommended by a doctor? From what I have read on the internet, I feel like I need a second opinion! I feel like no one believes I am in horrible pain. Please email me your response. Thank you so much for your time! Brandon

Q: I am an othewise healthy 35yo with nagging back pain for off and on for about the past year, I guess. It is located in my middle back-across the point where my rib cage is. It has not been bothersome during the day, but it wakes me in the morning--I have to get up because no matter what position I lay, it hurts. I am slow to rise and get moving, but once I do it does not bother me. I didn't think much of it, but have changed mattresses and it did not help. I have noticed in the past few weeks that it has become nagging during the day---it feels like a "catch" in my back just left of my spine at rib cage level. I have been to chiro in past for whiplash in my neck---and an occasional adjustment. She has adjusted this area, but it has not seemed to help. I am thinking that I may need to go to medical dr. to have them x-ray the area just to make sure there is not something growing there that shouldn't be. I have been reading the posts and am now wondering if it is psychosomatic??????? Any insight would be helpful! Erin

Q: Hi, my name is Yevgeniy and I had a back injury that put my basketball career on hold.I had an MRI done and it said I have a "Left Paracentral Disc Extrusion At L5-S1". My pain has gone away. This injury happened about 6 months ago. I had about 8 Division 1 colleges interested and now I'm taking a year off and grayshirting at a Junior college.I'm only 18 years old, does this heal on its own without surgery and will I be able to continue playing competitively? Thank you, God Bless.

Q: hi, i read a few studies that said 80% of the population will get back pain at some point in there life, i was wondering if you thought modern day lifestyle contributes to the amount of people that suffer with back pain or whether it has always been a problem? regards, paul

Q: Although i am experiencing lower back pain, it is not the reason for my inquiry. I have recently had what i can only describe as charlie horses in my neck/throat. I was using google to try and find some clues. I found the link to your website. This has happened on at least 3 occasions if not 4. The first time, i was laying on my back in bed early in the morning. I was just laying there stretching as i woke up, when a muscle or something in my neck/throat area felt like it was twisting inside my neck. It was paralyzing pain. It felt as though a muscle, tendon or vein was moved over and cutting off my airway. It was very scary. I kept grabbing my throat trying to move it back in place so i could breath. Like i said it was scary. In the meantime, after this happens my neck is sore for several days and my arm and fingers feel tingly. Do you have any idea what this may be? Thank you in advance for your time.Mimi

Q: Hi i'm 23 years old and seem to have a very strange sensation in my back when i bend over or make certain movements i feel a crackling, bubbling in my back under my ribs, its almost like wind i'm my back strange as that may sound. When i sit i seem to get discomfort in my neck and almost into my chest. I had a chest xray nothing seemed to jump out as being wrong. I have had this for 3 days now and although its not extremely painful its unsettling. the doctors don't seem to think its anything to worry about. I am going off traveling next week so am feeling very stressed out at the moment so don't know if this has anything to do with it, any help/advice would be greatly received. Erin

Q: i awake every morning after a very disturbed nights sleep which is not caused by the pain i want to ask about but i awake and i literally have to arise out of sleeping position from my front onto all fours slowly in agonizing pain sometimes it can take up to 10 mins for the pain to go then when the pain has gone i next get it in the morning next day. i have tried all sorts of remedys ie putting pillow under affected area,sleeping with board under bed, sleeping in different position but always i wake with pain around the kidney area of my back. i do weight training 5 days a week and running or rowing cardio exercises 5 days also my partner wakes me sometimes and helps me by massaging the area as i rise onto all fours i don't know what is wrong i am in agony. but as i have said the pain goes ten mins after and its fine the rest of the day so i thought it was my muscles relaxed whilst sleeping then tensing upon waking but i just don't know it's the same area all the time kidney area so i am worried it could be them i'm not taking steroids i am a heavy lad but do train heavy also can u help? Karl

Q: I would like to ask how you feel about the Tempurpedic mattress for people with several spinal injury. I have had 2 spinal fusion surgeries from a bad fall. I bought a Tempurpedic about 2 weeks ago. I tried 4 models at the store, and I picked what I felt was the "softest" ofthem all, although I used to really like a firm mattress. Well, the mattress I got feels nothing like it did in the store. This mattress feels like sleeping on a bed of cement, with a thin foam cover.

I don't know if it's (probably) just my spinal injury that is causing this to happen, but I can't find any site or anyone that can help me determine if it's the mattress, or me. I'm not particularly afraid it's going to hurt me further, but I'm now missing my old, firm Sealy coiled mattress. i heard it takes some time to adjust; is that my problem? Your thoughts would be greatly appreciated. Libby

Q: hi, i am a design and technology student at Manchester Metropolitan University looking at back pain i was wondering if you know of any products used for back pain which don't work very well, the problems with it.thank you for your time. Paul

Q: Hi my name is Lewis i'm 20 years old and this is my story and questions i have. since 2007 i was a plasterer and June last year i had to give up that job because of my back hurting me. It has taken me this long to find out i have spondylolysis after physiotherapy at the end of last year and start of this year, after time that began to be very painful. i then had to be taken to hospital at the end of August after shooting pains and weakening of my legs and back. after an MRI scan and a CT scan the consultant told me i have spondylolysis and it trapped my nerve, i have had this from birth but didn't come on till then because of all the heavy lifting i had been doing in my last job. the consultant told me i need to do more exercising to build up me muscles, even though physiotherapy was suppose to do that and it ended up hurting more. i am now confused about what to do, how do i know if i'm doing the right exercises? how do i know if i'm doing too much exercise? what am i going to do for a future job? will i ever end up living my life how i did? thank you for hearing my story and hope to hear from you soon. Lewis

Q: i am now 29 years old i started grinding on my teeth when i was 18 after starting a relationship with a guy. it turned out to be very tiring hence the start of my teeth grinding it continued and it became and still is aggressive ... i grind all night, i crush the mouth guards,and my jaw aches always, the right side of my jaw does not protrude when i open my mouth, the pain reached my neck,shoulders and i get severe migraines, nothing is helping i tried medication all sorts they affect only once then i have to double or triple the dose my bod quickly gets used to medicines, and i always thought of myself as a calm person now i'm just always angry and impatient,to top all this i have been suffering from facial pain as if electricity is passing through my face it only stays a few seconds and then happens again after a few minutes. i don't know what to do i have seen doctors they say no solution its all coz of stress and that i should rely on pain killers when I'm in severe pain Lara

Q: I have had back pain,pinched nerve for 10 years with pain coming and going. Finally in April this year pain so severeand foot dropped. Had low back disc surgery/decompression.Back pain and leg pain gone, however foot drop only partially gone. This foot and toes numb with occasional pain and several times excruciating every approx 28 seconds and two occasions approx every 3-5minutes lasting 5-6hrs. I have had therapy and take Gabapentin to no relief. Surgeon thinks problem will take care of itself. Any clues? John

Q: I'm 18 and I have been having terrible back pains for the past 2 years. The pain is just to the right of my spine and a little more than halfway down my back. The pain doesn't always come when I do certain activities it just randomly "stabs" me and when this happens it is not a constant pain it comes in surges that nearly bring me to my knees. I could get one bad surge and it not hurt for another week or it keeps coming back stab after stab. I've had my kidneys checked for stones and cancer. I've had my gallbladder removed and the doctors say there is nothing wrong with my spine and they pretty much are saying that there is nothing wrong with me. Is there anything else i could have checked? Thank you. Jim

Q: Are there any TMS practitioners, particularly pyschotherapists, in the Minneapolis/St. Paul, Minnesota area? I don't see anyone on your list. If not, do you take phone consults? Thank you for your good work! I can't believe I only just now learned of it, but am grateful for the improvements I'm already experiencing. I wish I lived in New York! Margie

Q: i have been diagnosed with scoliosis and arthritis i have had back pain since an injury years ago but it used to come and go. now with me not working it is there all the time. is there a herbal medicine i can take, as i already take some other meds and have had enough of them to so herbal is the way to go for me. would fish oil and omega3 be good for it or something else. look forward to here from you. Peter

Q: I'm an 18 yr old female. I injured my back falling off a horse 3 years ago. I have compression fractures of both my T12 & T9 vertebrae and something my doc called Smorle's nodes which she didn't really explain. Any way, shortly after i hurt mt back I started having extreme stomach pain that would last from minutes to hours. The onlyt hing that seemed to make it go away was laying down. I saw 2 specialist, one for my back & one for my stomach. The conclusion for my stomach pain was stress and nothing could be done about my back. The stomach pain went away for a long time, but now is back. With severe back pain as well. I was just wondering if the 2 were connected and how to lessen either one? Em

Q: Hello, Thank you so much for this website-it is truly informative to a degree that I haven't yet seen on the web on this topic!I am 19 years old and have suffered from terrible posture since I was a young teenager. I love reading and i never sit up straight when I read. Its gotten to the point that if I try s standing/sitting straight for more than 10 minutes, my back begins to hurt and i stop trying. additionally, I get occasional back pain (maybe once every two days.) I have gone to a chiropractor but got turned off when I realized that if they make a mistake they can pretty much mess up my spine. What do you suggest? So far i've heard of the following options: physical therapy, chiropractor, checking out the soles of my feet and whether i need special shoes, back brace or something to keep the back straight.. Please let me know what you think is best! Thanks, Michal

Q: Hello there, I'm only 22 years old and for now 5 months i have chronic neck pain. I have 24/7 muscle spasms in my neck and that is producing weird pain in my forehead, temple and even on the bridge of my nose as a result of the nerves passing near the suboccipital triangle being irritated. I passed a CT scan and some X-rays but the doctors told me i was fine ( i wonder if i can pass more test like MRI or looking somewhere else ). It all started 2 weeks after i heard my mom had a really bad terminal cancer ( lung and brain ). So i guess you might see a pattern there. I always been really strong mentally and a really informed person ( like i know a lot on physics, bio, chemistry and medicine etc ) i know the effects of stress on the health and everything and all of sudden it is happening to me.

At first i thought i was seriously ill like i thought i maybe had a mass in my neck or in my brain, then meningitis with no fever due to poor immunity oh well i will skip some. All i can say to keep it short is that it introduced me to anxiety. Now i have irrational fear of strokes and aneurysm and pretty much everything related to head and neck. So I'm stuck in this anxiety, pain, more anxiety, pain, depression circle. I started to do everything to feel better. I quit smoking, i started to go to the gym everyday and i eat very well now but the pain in my neck is always there, and now I'm starting to have lower back pain too. I guess it sounds familiar now... Anyway I'd like to hear from your experience and if you had some of the symptoms i had and if you think it's all due to my mind or maybe it's something more serious. I'm about to start treatment for depression and anxiety with meds and talk therapy. After seeing a chiro 3 times a week for 2 months with no result i will also start physiotherapy. Tell me what you think. Don't just tell me to buy your book, i might do so but i do not need to hear that.

My symptoms haven gotten so worse that i think i will die or something... I know it's not good to have a chronic stiff neck and lack of oxygen can lead to serious problems ( strokes are one of them ) so right there you can see my pattern of anxiety again...hehe. Best regards, J-S

Q: My sister is 46 and is now basically an invalid because of chronic back pain. She has had five surgeries and is worse now than ever. She was told she would never be free of pain, but would only be able to manage it with a pain management regimen. It is now working. She can barely move. She has degenerative discs, herniated discs, and I don't know what all. She lives in Oklahoma and is not wealthy, but if we knew we could fix her horrible pain and her bleak future, we would pay for the cure.Is your product something that can help someone in her condition?Thanks, Alice

Q: Hi, I suffered a 12 ft (approx) fall on my back landing on concrete. I have not worked in years due to this. I have pain in my lower back,right SI joint and right hip. I used to be pretty active and I'm only in my mid 30's. My back always hurts now,but the pain is at it's worst when I am walking or standing for any lenght of time ( 10 or 15 minutes tops). I then must sit or ly down for awhile before trying again.

I have tried physical therapy ( twice),pain medicine,injections ( one of them now gave me tightness in my lower legs) and manipulation. None of these have worked. I have been told my pain stems from my SI joint from some doctors and others from a degenerative disc at L4/L5. I have recently been told I am a candidate for disc replacement surgery. I am mulling that option over,but not to keen on the idea. They all say my hip is not the root of my problem. I was just wondering if you have any advice.Thank you very much. Ryan

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