Transforming Perspectives on Chronic Pain Management: From Opioid Dependence to Rehabilitative Therapies with Dr. Lysandra Jim

Full transcript

Hello and welcome to the Health and Fitness Room Defined. I'm your host, anthony Amen. Joining me today is to guide you into the health fitness movement, over from diversity to pick back your addiction and see health and fitness in a whole new light. Today we have a nice, fun guest right up from the PM&R world. So, my brother, if you're listening to this yes, we got another PM&R doctor on, so very interested to have this conversation with him and specifically to gear towards lower back pain, spinal pain something we've talked about quite numerous times on this show. But I do like getting different opinions because it's important to understand how to help specifically low back pain, because it is the number one complaint any doctor or any personal trainer will tell you that a client has. So, without further ado, let's welcome to the show. Like Sandra, jim, it's a pleasure to have you on today.

Thanks for having me on, anthony.

So the first question is why did you decide to get into pain management? What kind of get you started that way?

I started off as a physical medicine and rehabilitation doctor because I wanted to focus on not just purely medication for helping patients get better and it seemed a natural connection to have physical therapy and a lot of other kind of modalities to treat patients, not just pain medications. But ironically, after I finished my training I ended up being primarily a pill prescriber. I was a pain medicine doctor at a conventional pain clinic and in California, like many parts of the country, you have to go monthly for your opioid refills by law, and so I saw the same patients month after month and more or less the same medications, prescribing thousands of morphine equivalents, which is a measure of opioids per day, and I found the work very stressful and kind of depressing, because I wanted to become a doctor to help people reverse and heal their conditions, and here I was kind of palliating their pain, which is a great thing, but with something that is arguably far more dangerous than back pain or joint pain itself.

Yeah, and that kind of leads to the whole epidemic we have going on now. As far as fentanyl and heroin, and the opioid epidemic was the precursor to all of this, you saw tons of information coming out from the opioid prescribing of opioids and how they were uncontrolled in the streets and then, when they were pulled off the streets, people turned to other, more unconventional drugs. So it's a sad reality that it came from. I think this is an important description. A lot of people who ended up ODing on these drugs weren't like your typical drug addicts. They weren't people you would expect that would be addicted to these things. It was just they had a low back pain. They went in to go get checked. They got prescribed pain medicine, sometimes way too much, and then they just became addicted to it. So it kind of led down that rabbit hole and what you were talking about, where it's pushing pills and ultimately it's been a nightmare that we're still dealing with now. But I get it. I get the reason you wanted to leave and kind of do something else besides that, because it's sad reality.

I hear you and it's not a simple solution. I mean, if you'd say, don't prescribe these pain medications that the patients have had already, then their pain increases. They're more sensitive to pain, maybe more than ever. And if you pull medication, whether somebody is dependent on it for physical pain reasons or for, you know, addiction reasons, they're not just going to say, okay, I'm going to take ibuprofen, they're going to get it from other sources, whether that's another doctor or the you know so-called black market type courses. So as kind of a professional in the middle, you're trying to help people, you're trying to reduce their pain and the mechanism that you've been taught and you know these policies are largely from, you know, predate my entering medicine, opioids were not always a part of the chronic pain management for non-cancer pain. It was really a push by the federal government, along with some of these you know big pharma companies that kind of led doctors that changed the culture for them to start prescribing these medications. So by the time I started my pain medicine job, that whole debate was at a fever pitch because it was obvious that there was this tremendous opioid epidemic and it was becoming one of the leading causes of kind of death in the country and then. So then on the, it's kind of different as a kind of as a clinician who's well-intentioned and not you know, one of these corrupt people, pill mill doctors. you're just trying to help people. The people are coming and expecting a particular service and outcome and, I think, done responsibly. There are still risks. You're just risk mitigating but you only have so much time to spend with a patient so it becomes an issue of how do you know somebody really is addicted or not? Sometimes there's clear red flags, but most of the time in communication there's kind of this gray zone and so kind of in terms of the cognitive kind of load of like is this person saying my pain is high? Are they really suffering a lot of pain? It's. It just becomes a very confusing affair. So I was kind of happy to transition into a, an aspect of pain management and back pain care that was not centered around painkillers and opioids.

Yeah, and kind of add to your point that you don't really know. I want people to think of it from both sides of the coin. Right, it's important to say, like you said, a lot of the physicians didn't over prescribe opioids because they wanted the money. They thought they were actually helping people, because it was a huge push in your drafts. Right, it was in good intentions. And you walk into see a patient and you get what? Five, 10 minutes at best to get a good understanding of where the pain is coming from, how much pain they're in. You're not spending all day with these people. You're not spending hours with them to understand if they really are in pain, what they're doing. You get a quick, hear, the notes go and then you have to make a decision on the fly and then move on from it because your schedules are so overpacked, because they're trying to squeeze in as many people as possible, for you to see one shift. You're burned out and it's naturally human tendency. It's impossible for you to know where's my point. The little time you get with somebody, it makes it impossible to figure out if they are actually not in pain. The flip side of that is that even telling people and I experience this myself too. What's your pain rating of 1 to 10? People go all the time my pain's like a 10. Not understanding that if your pain's actually a 10, you shouldn't be able to say my pain's a 10 because you're in that much pain. We're just so afraid of hurting and not feeling normal that our pain tolerances have dropped A tiny little prick. I'm a 10 and a 10 pain. Help give me something. It's like. Well, no, that's not. I don't have anything to add to that, but it's kind of my point. It's hard to judge I do.

I think that's a central point is during the federal government's push to spread opioids, they said that pain was a vital sign. Pain is vital but it's not a vital sign In technical terms. Pain isn't even a sign in the strict medical sense, a sign. When you think about a vital sign, that's not something someone tells you. You don't tell me what your blood pressure and your heart rate and your pulse oximeter are. I measure those objectively. You can't really fake it. You could change your physiologic state, but the distinction is a sign, is objective and it doesn't require someone to tell you what it is. If you're making the mechanism for someone to get more or less or a stronger type of pain medication based on what is a symptom, then you're actually kind of opening Pandora's box, because whether the person has legitimate pain or is simply wanting more opioids for kind of other reasons, it's. I think that's what your kind of comments touched upon.

Yeah, exactly. I guess the next question and next natural push to this is what are the procedures that you think should be done, implemented, so it's not straight out prescribing your career? Let's say, somebody comes here and says listen, I have lower back pain. What are the next logical steps that someone should take?

Oh, that's a great question. I would say the first step is to understand the cause and the source of the back pain. So often in medicine such a pain is treated simply as a symptom, so it just means, oh well, you're hurting, here's a painkiller to mute that symptom. But then the reason you have a pain it has a cause, and then so the first aspect is to use a combination of clinical diagnosis. I interview you about your symptoms, when it starts, where does it hurt? And I get these details and that helps me start to form an idea about what the injury mechanism is. Then I'll do a physical examination and and then I'll test out my theory. You know, it's this mechanism. Maybe this bend would hurt it or this bend will relieve it. And starting with that, then we can move on to objective testing, things like spinal imaging, x-rays and MRIs. And usually most pain back pain it doesn't need an injection or a surgery. It needs quality rehabilitation based upon the injury mechanism to recover.

Yeah. So let's talk about that. Let's give a specific example, and I think what comes to my, I think what comes to my mind first is most people will end up pulling, like turning it in a disc. That's probably the most common cause for lower back pain. I can't tell you how many clients they're like oh, I blew my back out. How do I do it? I twisted this way, so you're turning in the transverse plane and you're grabbing something from the bottom and then you're twisting back up quickly that you blow a disc. Your lower back hurts. So if someone has, let's say, herniation in the lower back and it's causing reading and pain, so we know that there's nerves involved. Where are we going from here?

The first step is to figure out the level of the pain, so, for example, an MRI. In that case, if we're focusing on disc injury, which is the most common type of significant back injury, you're usually dealing with some type of disc bulge. And so on the clinical side, the first thing we're trying to figure out are what was the cost? And then I think he gave a very specific biomechanical description, like twisting with a side bend and a load, and that starts to inform the hypothesis of how this person blew out the disc. And then the next step would be to figure out what makes that pain worse, because a disc injury that has sciatica, which that's kind of like the typical pain presentation, there's actually a lot of different subtypes of that injury, and so some people they get pain in their big toe, or other people get pain at the bottom of their foot. So then a clue like that might suggest oh, a different nerve root is involved. Some people, when they round their spine, their pain gets a lot worse. Other people with sciatic symptoms, when they round their spine and sit slouchy, their pain gets better. And so there's all these further physical ways you can subcategorize these injuries. And so with that, without even quite yet. Knowing the exact this level, I can say well, these things hurt you, these things you tolerate or make you feel better? And from that information you can begin to design a coaching program based on posture, movement and exercise that is tailored to that person's unique sciatica presentation.

So we can start with posture just as a general understanding for most people, because our posture here in the States is horrible. So many people have poor posture, especially now that we're sitting at desk computers more and wearing our phones. I see a lot in the gym is the pressure on the lower back because of poor posture, not sitting upright. So what are some techniques you can give to help with? What are some posture techniques basically that somebody can do to mitigate the pain from sciatica or prevent it?

Well, the first tip is to avoid postures and movements that worsen the pain. That might sound like a kind of like a snarky comment, but in reality when I see patients they don't know that. Many of them say, oh, this exercise first, I'm supposed to stop it, because they don't realize that pain is a signal of tissue damage. So I would say that, step one simply don't do any activity, even if it's walking for a bit too long, that hurts you. The next step, which would be based on what you learned from the assessment, would be to tune the posture. The correct posture is usually close to something called neutral. That's the position in your spine that the discs, the ligaments, the muscles, they're kind of in that sweet spot where they're not stretched out, they're not twisted, they're not loaded in any which way, and usually the correct posture is somewhere in that area. And the quick way I have for teaching people that is do you play any sports by chance? Yeah of course, can you give me some sports you play.

Basketball, volleyball.

OK, ok. So yeah, we've worked with some volleyball players. So in most sports there's something that is akin to a ready position. It's this position where you're standing and you're waiting for something to happen, but you're not quite engaged, like that, next action isn't to you, it's to your teammate, but maybe it's before you're going to spike the ball.

You're watching your teammates, so you're on your toes. You're sitting down into a semi-squat in your back, yeah, or?

like a taller version of that, like maybe you're on a semi-squat, maybe like a taller version where you're standing there casually, because what people tend to do is, why is it that the ready position? It's because they're kind of not tense, they're not really stretched one way or the other, they're not puffing their chests out like they might do in their regular life, and so I would say that ready position it could even be in the occupation. I saw a butcher and then he was standing, chest poking out, shoulders pulled back, hips extended. I said how do you stand in front of the butcher block? And then he says, oh, I just sound like this, everything relaxed, or was this ease to his movement? So I would say the second step is finding the sweet spot in terms of posture, and that sweet spot becomes a foundation from which you feel other movement. So then you allow the movements You're trying to keep that near neutral spine and then move, like whether you're doing a squat or a pull, trying to keep that motion. And I would say the third thing is your body needs a variety. No matter how sweet I shape my spine, if I'm just sitting there all day or I'm a Buckingham Palace garden, I'm standing there all day, you're going to ruin your joint health, your cardiovascular health. We need variety as well, and that's often the element that people talk about. We don't need to be walking all the time, nor do we want to be sitting all the time or standing all the time. It's really a mix of those things, and so even if you have probably many gym goers who they sit at their coding job all day, 8 hours, 12 hours and they come to the gym, they're still not going to be that healthy because there's just too much of one thing at a single time. So I would say those are kind of three ideas to get you started.

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I would just start off with a brief qualifier. Is it? There's no spine exercise or universal exercise? That's good for every sciatica or disc voltage patient. But then I would say it might be best to start off with what messes up the disc more. Maybe that would be a good place and that will kind of inform what is safer for a disc. A disc is injured by excessive bending, twisting and loading. So you know, flexing, extending, twisting it too much, putting weight on your back that your spine is not strong enough to take on. And so some common gym exercises that replicate these type of mechanisms are certain stretches like hamstring stretches, where you're rounding your spine. In that case not only are you flexing your disc and stretching the back fibers of the disc, you're also creating tension on the sciatic nerve. So things that stretch the hamstrings also stretch out and damage the sciatic nerve. So we see many patients who keep themselves in pain from a stretching program in that way. Another thing that hurts that we commonly see are things that repeatedly flex the spine, sit ups, curls, all of those variations. You're actually further propagating the injury mechanism. In those cases. If this disc is injured, it's injured from too much bending, twisting and loading, so it definitely doesn't want more bending and twisting. And so if you think about sit ups, you think about knees to chest. These kinds of things replicate that kind of bending mechanism, and sometimes the bending is accidental. It's that so-called butt wink at the bottom of a squat. So that's a bend that's occurring under tremendous loads, and then that's probably the worst thing you could do for your disc injury. So what helps the most disc injuries? There are usually things that involve stabilizing the lumbar, spine and torso muscles, and these are as a category. They have a lot in common and include planks. So planks, as you know, it's an isometric exercise. Your spine position doesn't change during the exercise. You're getting into a position and you're holding that position to resist some sort of challenge, right? So then, one of the starting points for a standard spine patients that will work for many disc patients is something we know we described often as the McGill Big Three. That's, the burr dog, the side plank and an exercise called a modified curl, and all three of those exercises they train different parts of the spine and the torso, because we often think about the spine as just the back, but really it's a 360 structure that's supporting it. It's like a barrel around the spine, with the abdominal muscles at the front and the sides and finally the back muscles in the posterior aspect. And so you're really trying to develop. A lot of the goals are learning to develop first, quality movement patterns, which usually involve holding the spine stable. Two is developing endurance in the spine, because endurance is what's going to keep you from fatiguing and losing your form during your everyday life and during exercises as well. And so I would say the Big Three. There's certain poles, especially with TRX, like the TRX, low row is often the good one. Pushups, which is a pushup, is a plank exercise with the additional component to it. Certain types of front plank and front plank variations can be helpful. And then these, of course, are more exercises for rehabilitating patients. It's not the end all be all if there's an athletic goal at the end. And, as you see, with different athletes, the proper training program will depend on the sport and the position and the person's unique characteristics as well.

And I'm gonna break down in really stupid layman terms exactly what you said for everybody else, please. It was great, though, so, if you took your spine and if, for those that are audio, I'm gonna just use my hand as a visual and it's straight up and down, and I took a load and I went straight down. This way, this position, your spine can hold the most amount of load. This is where it's the strongest, right here. The second strongest, or the middle, is this way, pushing it from the side straight in to the spine. This is your flexion extension. It can take a decent amount of load this way. The absolute worst way to take a load in your spine twisting, sitting anything in your transverse plane. So a good example of this would be a Russian twist, as a lot of people throw a lot of weight on that one, and it makes me wanna cringe really hard, especially when they do it fast, because you're throwing weight quickly from one side to the other while twisting your body. Your spine can't handle a lot of pressure like that. That's why it pops a slip of disc. It's exactly what the example I gave you when you're so in bends over and twists to grab something and pulls it up through. So that's kind of what you're going into as far as good bad looking at it. Never heard the thing about the hamstring stretch before. Very interesting point. Makes sense when you explain it. And the other point you mentioned was butt-winking, which is you're exactly right. A lot of people get that, especially when they're not being watched. They'll get the little spine will kind of curve out like this and you're getting a lot of weight pushing in the awkward direction against your spine, especially for squat and heavy. Easy recommendation change it to sit stands, then still squat. If you wanna keep your weight, keep your weight. But if you go straight down to a sitting position it's gonna prevent you from throwing your butt all the way out. So go a little alternate there. I have a specific exercise for you. If you don't know the name of the exercise, it's fine. I absolutely hate it. I actually have four band workouts that my trainers are now allowed to teach in our gym. Yes, we have a band workout list because people come up with the craziest stuff. One of them had gained a lot of popularity, so I'm never allowing it, but wanna hear your reason. You know what a good morning is.

A good morning. Is that different from a Jefferson curl? Is that?

Yeah, a good morning is. You know what a stiff leg deadlift is? Yes, yeah, so it's that movement of a stiff leg deadlift, except you're loading a barbell exactly where you would put a back squat. So in a back squat, the barbell's here Now. So I'm loading this direction and then I'm basically just bending over like a stiff leg deadlift.

Okay, I think I know it's almost like a hip hinge, where you don't round your spine but you're loading your back like it's a back squat.

Yeah.

That's a good morning.

Oh yeah.

So I think that it's certainly a high-risk exercise. I'll give one that is, I think, even more band, and maybe you can tell me if it's on your list or not. All right, Because if I mean a good morning. It subjects the spine to two big forces. One is there's that downward compression one that you're showing where your spine is there's a weight pressing down. But then when you bend your spine over then there's another type of force that happens. That's called a shear force, like a slipping force. And so if you do that exercise and let's say you're able to keep perfect form, you might be able to tolerate it, but the rate of injuries going to be high because there's a good chance you're going to bend your spine. And the other point that's more important than and why you're rightly concerned about it is sure force is even more dangerous than compression force on its own. So there's the NIOSH, the National Institute of Occupational Health and Safety. They put out numbers about well, how much of this load can your back take before you're probably going to get injury? Or that load, the load that you can take for sure is about a third of the amount you can take for compression. So you're trying to avoid this exercise that has compression and shear, but I would say even worse than that is the Jefferson curl. So that's an exercise where you're standing, you're holding often you're holding the weight to your side, but you're kind of leaning over and intentionally rounding your spine segment by segment. I mean you can hardly design a better exercise to destroy this, because you have the potent combination of the compression load, you have shear load and you're rounding your spine, which destabilizes it and crushes down on the disc in the front stretches, the nerve of the annulus kind of collagen fibers in the back. So you can create injuries fairly quickly if you give a Jefferson curl to most people.

It is now going on or less.

I would say that's even more evil than the good morning it's a good morning.

I think there's a select few.

There's like a very genetically gifted athlete. People might pull it off Jefferson curl. It's even worse.

Yeah, definitely not that, and we don't have this machine, so thank god. But I know the bigger gyms they have it. It's basically mimics, a Russian twist, and they call it spinal rotation. So you're under your knees and you're upright and you're pressed up against the machine and you use your hips to turn to the side and you can load like 200 pounds. You're just watching people. They're just this way, they're turning their hips the other direction and I'm just like, oh my god, no, stop stop. My point being, without going into 600 different rants, there's a risk versus reward. For every exercise. You have the potential of getting hurt, doing absolutely anything. You can walk to your mailbox, which is probably one of the safest freaking things to do and highly recommend indigachipant fall Like. There's risk reward to everything, but our point being this exercises that are not worth the risk and have alternatives that are way safer, because the last thing you want and trust me from experience is to hurt your spine because it doesn't really heal. So just take that into consideration when you're doing certain things at the gym and, if you're questioning, ask the professional and not just anybody. Don't ask your friend you're working out with, who's also 18 years old. Go talk to somebody who does this for a living and you'll understand and email me Happy to answer you. Guys, I have very passionate about some exercises we don't allow, so definitely, definitely recommend. So we've gone through postural, we've gone through the fitness kind of do some don'ts for you. Is there anything else that you think people should incorporate to help either get over a back injury or help prevent?

Yes, another. The first thing that comes to mind is if you're back and take it, which is most of the time walking. Walking is the original spine exercise. We don't think about walking as a spine stabilizer, but it absolutely is. When you're walking you're moving forward through spore momentum but your spine isn't really wobbling or jack-n-nacking forward because your muscles are very precisely just keeping the right level of tension and control. And then walking naturally has variety where you take, you know step with one foot, another, because it's a symmetry to it. But it evens out because you're doing it equally, learning what the right way to walk and and how much you can walk. That there's a pretty big range for that. And then I would say also, training sensibly is a big thing. I think a lot of people are often in the gym. They're kind of working out their demons is the sense I get. I mean, and then and then that's fine if you're, that's fine on a mental level. I think it's very helpful. But you actually will get into a darker place if you do it so well that you don't respect your body and you're overtraining yourself. And I find that there's a lot of people who they don't, they don't really know why they're training exactly. They know it makes them feel better, but then they're so aggressive about it in terms of the amount of exercise and load they want to take on and they're, you know, they're just kind of, you know, desk jockeys like us. We're just, they're sitting around most of the day. So really, uh, the sensible training, avoiding that injury and I know you said earlier it's quite hard to heal some of these injuries. I mean even spine injuries, disinjuries. They can heal. Vast majority can heal with the right direction and therapy program. But you don't want to take yourself out of that, put yourself in that hole. You don't have to.

Yeah and just one more hard question, just because it's something that it's personal to me Spinal surgery. Are there cases that we wouldn't recommend something like a lobidectomy that I've seen gotten horribly wrong, as opposed to finding different alternatives? Because I don't know if it's overly pushed because of the pain, because they can get your insurance for a lot more, or if it's actually needed. But I mean, I'm also full disclosure on this. People don't come to me when spinal surgery goes great. They come to me when they screw up spinal surgery. So I do see it at higher rates than most people. So I can admit that. But I don't know. I kind of wanted to leave it up to you if you thought it was something that's feasible or kind of a last resort.

I think that there's truth in both things. You said Spine surgery is over prescribed and I also I'm in your position too, where your spine surgery went so great you're not gonna find a clinician like myself to see. But I would say that there are instances and I could think of some even within the last, you know, two, three months where I've referred patients for surgery because it was the only safe choice they had. I'll give a classic example, because many, even clinicians missed this diagnosis. It's a dangerous compression of the spinal nerve roots. So think of it as it's almost like the worst sciatica you can imagine. You're not just the disc bulge and other palms are compressing not just one nerve, causing, you know, zapping pain down the leg. It's crushing so many nerves that it starts to affect the bladder. So some of these patients they can become incontinent, they can get sexual dysfunction like erectile dysfunction of a very absolute kind, and they can get even loss of bowel function. And the kind of fascinating thing about some of these injuries is sometimes there's not even that much pain Like. Sometimes the main symptom are some of these neurological deficits. And because it's not pain, it's not sciatica, some of these patients don't recognize that it's actually coming from the spine. So this specific syndrome I'm describing is called Cate Aquinas Syndrome and I find that in those cases most Cate Aquinas syndromes need surgery. And so then there's different ways you can kind of figure out if you need surgery. I mean, you always want to be doing this under the guidance of your medical team and it should always include a doctor. And it should usually include doctors who are not just surgeons, because that's true If you're, you know, if you're a therapist, many things look like therapies. You're gonna fix it. If you're a surgeon, and it really depends on the case, who has the right answer. But I find that if you have a good team, including non-surgeon physicians and surgery physicians, if there's any disagreement, get a second or a third opinion about it. And I would ask for advice here listeners, don't tell the other doctors what your diagnosis is. Don't tell them what the other doctors said, because you know, I think some of us are very agreeable. So will this kind of not kind of agree just because it's kind of? There's like this kind of social element to it which I don't think is so great, but that's kind of how medical systems work, especially if you're seeing a second opinion within the same practice. That's almost like seeing getting the same doctor, because the first doctor can see the note of the original doctor, and but then I would say, go to a different health system. Don't disclose that, at least at first, what the other doctors say, and often tell my patients that they said. They'll say, oh you know, I saw this other doctor, I don't know, earlier today or last week and I said, okay, don't tell me what they said, I'll tell you what I think and then, if it converges, you'll know. I'm not just nodding my head in agreement. And so I would say most of the time, I would say most surgeries would say somewhere above 90, 95%. I would say let's just say 90% of surgeries. Up to that many can be avoided, depending on the indication. Because there's indications like the Codic Pine Syndrome where you just send at least for surgical evaluation, you just send 100% of your patients virtually for at least the consultation, and then there might be some special reason that they shouldn't get a surgery. But that's kind of how I would think about it. Get it down to the diagnosis of what's the problem, the nature of the problem, and even some kind of classic sciatica. Imagine. I tell you sciatica, no posture changes the pain. It's severe pain all the time. The leg is melting away, the calf is gone, the person's gluteus melted away because of the lack of nerve signal to it and it's progressively getting worse. So these are situations where it's not as clear cut as Codic Pine but they may very probably need a surgery as well.

Yeah, I love that answer. It was very informative. So, lysander, I'm gonna ask the final questions. I ask everybody on this show, just to wrap it up. The first one is if you were to summarize this episode in one or two sentences, what would be your take home message?

My take home message is injury is caused by the wrong kind of accumulation of posture movements and loads and exercises, and it can often be healed by the correct combination of posture motions, loads and exercises.

I like that. And then the second question how can people find you get a hold of you? I know you wrote a book, so please go ahead and give us all the information for that.

Oh, yes, the book can be found on Amazon. The title is Specific Spine A Doctor's Guide to a Healthy Pack, and it can also be found on my clinical website, masterymedicalcom.

Love it, sandra. Thank you for coming on. I think you guys will listen to this week's episode of Health and Fitness for Define. Don't forget, hit that subscribe button and join us next week as we dive deeper into this ever-changing field. And remember fitness is medicine. Until next time, dag.