WHAT MAKES SO MANY OF US SO SUSCEPTIBLE TO LOW BACK PAIN?
Did you ever think that our posture, the chairs we sit in and our sedentary lifestyles could set up the conditions that make us all susceptible to episodes of low back pain? This video will explain how these are all interconnected and show you how they can lead to developing long lasting low back pain. If you are currently suffering from low back pain, understanding these connections will relieve you of some of the agony of low back pain that comes from not understanding how it happened to you in the first place and why it seems to persist no matter what you try to to do about it. This video is presented by a basic scientist who has spent most of his career studying pain pathways at the National Institutes of Health (NIH). Here is what you will come away with if you watch this video: An understanding of what a normal, healthy posture looks like compared to a posture that has been deformed by sitting in poorly designed chairs that is part of living a sedentary lifestyle. An appreciation of how postural deformations change how low back muscles and abdominal muscles function and how these changes make you susceptible to low back pain episodes. What early postural deformities can lead to if they are not corrected. What you can do to return changed low back and abdominal muscles to their normal, healthy state and reduce their susceptibility to low back pain.
SIX REASONS TO CONFRONT CHRONIC PAIN AND NOT JUST LIVE WITH IT.
This video gives you six reasons why it is so important to confront chronic pain and not just try to live with it. If you do nothing, nothing good will happen and most likely the pain will get worse. When pain has persisted for more than three months, affected muscles and many of the nerve cells inside our nerves, spinal cord and brain change the way they function from their normal, healthy state. Muscles shorten, develop sites of sustained contraction, lose parts of their range of motion and exist under excessive tension. Nerve cells can stay active long after an initiating stimulus ends, increase the area of the body they respond to and secrete chemicals into muscles that keep them in a shortened and inflamed state. Allowing these changes to persist increases the chance for damage to joints and their cartilages. In the case of the spinal column, for example, when there is long standing low back pain or neck pain, the disks that lie between the vertebrae are put at risk of getting damaged.
These changes largely explain why long standing pain is so difficult to treat with a either a single exercise or drug. These changes also underlie so much of the agony of chronic pain where no matter what single rehabilitative effort you try, the pain does not go away.
However, there is a way out of this dilemma. The changes that have occurred to the affected muscles and nerve cells can be reversed. Lost range of motion can be regained, sustained contractions can be ended and nerve cells can be returned to their normal state.
WHAT KIND OF INFORMATION DO YOU NEED TO CONFRONT YOUR CHRONIC PAIN?
This video offers you hope that there is a way out of chronic pain (CP). It introduces you to the kinds of information you will need to be able to successfully confront your (CP). It introduces you to what happens to your normal healthy pain pathways and muscles when there is a CP episode, how posture, chairs and our sedentary lifestyles set up the conditions that lead to CP, and how CP causes destructive changes to our pain pathway nerve cells in the brain and spinal cord that then prolong CP episodes. It explains how by ridding shortened muscles of sites of excessively prolonged contraction, using static stretches to recapture their lost range of motion, doing away with their excessive tension and strengthening them by moving them through their full range of motion you can return them to their pain-free state. You will find this information very encouraging because all of the techniques that will be presented can be done by yourself, at home and without the need for expensive equipment.
HOW DO HEALTHY MUSCLES NORMALLY ACT AND HOW DO THEY BECOME SOURCES OF CHRONIC PAIN?
This blog will introduce you to several basic concepts of how muscles function normally and what happens to them when they become involved in chronic pain. Before you can take any effective remedial actions to restore muscles involved in chronic pain to their normal healthy state, it is critical to understand exactly how muscles act under normal healthy circumstances.
All muscles attached to our bones and joints are called skeletal muscles. They act to move body parts by shortening, i.e., by contracting, followed by lengthening, i.e., relaxing. The distance between a muscle’s fully contracted location and its fully relaxed location is called its range of motion. When a muscle’s normal sequence of smoothly contracting and fully relaxing is disrupted, it loses part of its range of motion, develops focal sites of sustained contraction inside itself which makes it susceptible to injury.
If this situation is not remedied, by eliminating the sites of contraction inside the muscle and restoring its normal range of motion, the nerves inside the muscle and the nerve cells they connect with inside the spinal cord and brain can become damaged. If this happens, then our normal pain pathway circuits become permanently altered. It is through this sequence of events that a muscle can become a source of chronic pain.
Skeletal muscles for the most part fall into one of two categories, flexors and extensors. It is critical to understand the differences between them before being able to take effective remedial actions.
When flexors contract, they move the bones of a joint in such a way as to decrease the angle of the joint they act on. When extensors contract, they do the opposite, i.e., they move the bones of a joint to increase the angle of the joint. Many of the most powerful muscles of the body are flexors, for example, the biceps in the arm, the abs in the trunk, the hamstrings in the thigh, the closers of the jaw and the pectorals in the chest. If a flexor does not fully relax and remains in a somewhat contracted state it will not function properly and it will also adversely affect the extensor that works in opposition to it. In such a situation, the extensor will be under excessive tension because it will be unable to fully relax. This sets up a situation where, if it persists for a long enough time, the extensor will only be able to move through part of its range of motion and it will ultimately become chronically painful. In so many chronic pain situations, extensors held under tension become victims of shortened flexors who are the culprits.
Low back pain is an example of this situation. What typically happens in low back pain is that the abs become shortened and put the low back extensors, which run along the back of the spine, under excessive tension. If this situation is not corrected, the back extensors will begin to hurt and very soon become chronically painful. This example illustrates what is so frustrating and downright infuriating about chronic pain. No matter what you might do to the back extensors to get relief like, for example, applying heat or cold, massaging them, taking anti-inflammatory medications, the best that you can hope for will only be temporary relief. The pain will inevitably recur until the tension in the lower back extensors (the victims) is relieved. Fortunately, there is a way out of this situation as well as other chronic pain situations. They are described in detail in my Book (A Way Out Of Chronic Pain) and will be addressed in future Blogs.
The final point of this blog is get you to appreciate that all of the skeletal muscles of the body, and there are over six hundred of them, are in a two way, continuous communication with the brain. Information flows into the brain over sensory nerves and back out to muscles over motor nerves. It is the brain, acting through this two way communication, that sets the tension level in each muscle. The only way to permanently change the tension level in a muscle is to get the brain to reset it. It takes great effort and many repetitions of movements to make such changes happen. This is the reason that chronic pain is so frustrating and difficult to address because it does not lend itself to one step solutions. In future Blogs we will consider how to get the brain to reset the tension level inside of muscles and increase their range of motion.
TO CONFRONT OR TOLERATE CHRONIC PAIN? THAT IS THE QUESTION
If you have been experiencing pain that has lasted for a month or longer without it showing any signs of getting better or resolving on its own, you face a dilemma. And that is what to do about it? There are only two choices; either confront it and try to do something about it or try to avoid and just tolerate it. The first reaction of most of us is to try to live with it. Last month’s blog touched on the kinds of thinking that most of us go through as we try to live with the situation. Because this is such a critical decision in trying to alleviate chronic pain, it is worth examining what most of us go through in trying to decide what to do,
What follows is a very typical experience of a person in chronic pain and the decisions they make, in this case, living with chronic knee pain. A bunch of us including me, a physical therapist and the sufferer were sitting around having lunch and just chatting.
Sufferer: “You know, my knee is killing me”
Me: “Have you been through physical therapy?”
Me: Did it get better?”
Sufferer: Yes, but I haven’t kept up with my exercises.
Me: You know, you really should restart the exercises especially since they seemed to help you in the past.”
Sufferer: “ You’re right, but I just can’t seem to get them going again.”
Me: “Read my book. It will lay out a simple set of things you can do at home that will help you.”
Physical therapist: “Or if that doesn’t work, come back to the clinic and let the therapists work on you”
Sufferer: No response.
Sometime later in the conversation:
Sufferer: You know I recently went on a vacation and sitting on the plane for the four hour flight was hell. I ended up taking three ibuprofens and it still didn’t help.
Finally, as we got up from the table to leave:
Sufferer, vigorously shaking his leg: “My knee is killing me.”
This conversation embodies the kind of reaction that most people have to a chronic pain experience. Even though the pain is intense, unrelenting and has been going on for some time, there is tremendous amount of emotional inertia that gets in the way of trying to do something about it on a regular basis. The inertia reflects the despair and feelings hopelessness that is at the core of the chronic pain experience. It also so often reflects a lack of knowledge about what is causing the pain and exactly what to do about it beyond simply taking some pills which usually give only very temporary relief at best. What is so difficult to accept is that the conditions that have brought you to your current state of an ongoing chronic pain state have existed for some time and that there is no one step solution to it. What has to happen is that a sustained effort, lasting over weeks and probably months, will have to be undertaken to eliminate the conditions underlying the chronic pain.
Making a start is the toughest step you will have to take. Once taken, you will see that the pain is not destined to get worse. You will feel better emotionally because you have begun the journey back to a pain-free existence. After a few repetitions, it will become apparent to you that getting back to a pain-free existence or at least achieving a marked reduction in the pain intensity is possible with simple steps that you can take at home, without a lot of expensive equipment and without relying on drugs. What you will have to do is identify the muscle(s) causing the pain, eliminate sites of shortening inside of them and find ways to either lengthen them if they have shortened or relieve them of any excessive tension they might have developed. How to do this is explicitly laid out in my book entitled, “A Way Out Of Chronic Pain”.
Success is achievable!
WHAT KINDS OF NEGATIVE THINKING DO PEOPLE EMBRACE THAT PREVENTS THEM FROM CONFRONTING THEIR CHRONIC PAIN? WHAT CAN BE DONE TO CHANGE IT?
In a recent conversation I had with a physical therapist who had been in practice for over thirty-five years, the most frustrating thing he had encountered was that only thirty-five percent of patients presenting for treatment of chronic musculoskeletal pain would do their prescribed exercises at home between therapy sessions.
Sixty-five percent would not. This is astounding! After all, this group of people was in the midst of suffering with debilitating chronic pain that was severe enough that they were prescribed a course of professional treatment by their doctor.
What would explain why so many of them could not be motivated to regularly perform a group of what are relatively simple exercises that would relieve their pain and prevent future recurrences? Let’s look at some of the most common reasons and see if there are any solutions to them or at least some work arounds.
1. Cultural reasons: If exercising has never been a regular part of a person’s life, especially for people over fifty, it is difficult for them to start now, even in the face of debilitating chronic pain that is diminishing the quality of their life. Solution: Begin slowly. Try to devote five minutes each day to performing rehabilitative exercises. Keep increasing the amount of time until you are devoting enough time to be able to complete the entire prescribed regimen. Try not to backslide. If you miss a day, do not quit. Just pick it up again the next day.
2. “It hurts and I am afraid that by exercising, I will make it worse.” This is very logical thinking. However, despite being logical, it is wrong. If you do nothing, it will get worse. If one wants to get better, one has to find a way to confront the pain. Solution: Find a way to move the affected body part without increasing the pain. When first beginning, it may be that you can only move the body part a few millimeters and press only very lightly on the contraction spots inside the affected muscles. This is exactly what initial progress looks like. With daily repetitions, the body part will be able to move greater and greater distances without an increase in the pain.
3. “Maybe if I leave it alone, it will get better on its own and go away.” Just like reason 2, this thinking feels very logical. However, just the opposite is true. What current scientific research has shown, is that if the pain has not gone away in two to four weeks, it will not go away on its own and very likely will still be present months or even years later. Solution: A change in thinking will have to be made. A new attitude will have to be adopted; one that embraces sentiments that include the following: “I am entitled to live without chronic pain; I will do everything in my power to confront the pain; I will not get discouraged; and I will persist in trying to achieve this goal no matter how long it takes.”
4. “I can’t get down on the floor. It hurts too much.” Indeed, you may hurt too much and be too immobile to get down on the floor and get back up again. However, this is not a reason to do nothing. Solution: Every movement, exercise and application of pressure to contraction spots that calls for getting down on the floor can be done comfortably while lying on a bed.
5. And finally, the ultimate rationale for not confronting chronic pain: “I am a very busy and a very important person and I just don’t have the time”. Hmmm. Indeed, you may be! However, If you continue to neglect your chronic pain and continue to do nothing, you will find yourself becoming less “busy” and less “important” as your chronic pain inexorably robs you of your mobility, energy, vitality, sleep and your joie de vivre. Solution: Carve out the relatively small amounts of time from each of your busy days that is needed to stop the progression of the chronic pain. The gains in the quality of your life are simply to great to be neglected.
One way to get started is to read The Book entitled, “A Way Out Of Chronic Pain, How It Happened and What To Do About It” [https://store.bookbaby.com/book/A-Way-Out-Of-Chronic-Pain]. This book will show you how to identify which muscles underlie chronic pain states in all of the major body parts, how to eliminate sites of shortening inside of them, how to lengthen them if they have shortened and how to relieve excessive tension inside of them. If you can accomplish these goals, you will have taken an important step in regaining lost range of motion and eliminating sources of chronic pain that may be affecting you.
WHAT ARE THE CONSEQUENCES OF NEGLECTING OUR SKELETAL MUSCLES BY ALLOWING THEM TO SHORTEN AND LOSE PART OF THEIR RANGE OF MOTION?
Chronic pain, like so many other chronic conditions, is easier to prevent than to cure. If you are over fifty and lead the typical American sedentary lifestyle, many of your major muscle groups, like your abdominal muscles, lower back muscles, hip flexors, thigh muscles and chest and shoulder muscles are probably neglected. They are probably tight, harbor multiple contraction spots and function only through a small part of their normal range of motion. Consequently, they exert excessive tension on the joints they attach to and are susceptible to “pull” type injuries. If you do nothing about this and let this situation continue, you are highly likely to be on a glide path to a chronic pain episode if you have not already suffered one.
What is so often difficult to face is that we will have to devote part of our day to remedying this situation by engaging in some form of body maintenance of our skeletal muscles if we are to keep chronic pain at bay. It is ironic how most of us are quite willing to devote time trying to prevent other chronic diseases or at least keeping them in check. For example, we are quite willing to engage in some form of aerobic activity to avoid cardiovascular disease and we are quite willing to regularly brush and floss our teeth and have our teeth cleaned to avoid periodontal disease and tooth decay. However, when it comes to the biggest part of our body with at least half of our brain devoted to it, namely our skeletal musculature, we barely give it a thought, no less regularly tend to it.
There are many dire consequences to this neglect. Tight, shortened muscles are at the heart of so many chronic pain states that affect so many different parts of our body. If remedial steps are not taken, what is highly predictable, is that the situation will get worse and the muscles will continue to shorten and lose more of their normal, healthy range of motion. The consequences of this is that muscles will be placed under excessive tension, joints will be damaged and postural deformities will occur like rounded shoulders and bent over stances at the waist. In addition, changes will takes place in our normal pain circuits in our brain and spinal cord that will make us more susceptible to chronic pain. These changes, in turn, will lead to a decrease in our mobility and a loss of muscle strength. Such changes are at the heart of the state of age related decrepitude as well as the sense of not being able to get around much anymore like we used to and to feeling “old”.
What can we do to avoid riding down this dismal glide path? The answer is putting a daily three pronged approach together that will recapture and retain our muscles’ healthy, normal range of motion. Such a program will involve eliminating sites of contraction inside our muscles, trying to lengthen them by applying static stretches and moving them under load through their full range of motion. How to do this is for each of the major muscle groups in the body is outlined in detail in The Book which can be found at https://store.bookbaby.com/book/A-Way-Out-Of-Chronic-Pain
WHAT HAPPENS TO OUR PAIN CIRCUITS WHEN THE NERVES CONNECTING MUSCLES AND THE SPINAL CORD GET INJURED?
In 1984, while I was studying the effects of a nerve injury where an injured nerve was unable to repair itself and reestablish its former connections inside of muscles, it became apparent that, in addition to the injured nerve cells, the nerve cells that they connected to inside the spinal cord were also getting injured. This discovery indicated that the effects of nerve injury were much more serious and widespread than previously appreciated because they extended to the entire pain circuit of the injured nerve. This finding in part provides an explanation for why so often a chronic pain experience will long outlast an initial injury or traumatic event.
Since that time, many other changes in pain circuits following nerve injuries have been discovered. For example, injured nerve cells release several different chemicals like substance p and nerve growth factor into their affected muscles as well as from their endings in the spinal cord. In addition, the environment surrounding pain neurons in the spinal cord that transmit pain messages to the brain also changes. For example, glial cells surrounding injured spinal cord neurons start releasing chemicals around these neurons that increase their activity. All of these effects contribute to the continuation of the activity of nerve cells in pain pathways that contribute to the sustained, unrelenting quality of the chronic pain experience.
After nerves have been injured, there are two kinds of activities that contribute to this relentless quality of chronic pain. First, the nerve cells inside of the injured nerves begin to respond to events that were previously not considered painful, like light touch or pressure. They also begin to respond to new areas of the body that previously lied beyond the more limited areas that they used to respond to. These changes fall under what scientists call allodynia, i.e., injured nerve cells that now respond to events that were not previously painful but now are.
The second activity involves nerve cells inside the spinal cord and brain pain pathways that receive inputs from the injured nerves. These nerve cells now maintain their activity longer than they used to. They will often exhibit a behavior called windup where they will respond to successive inputs with higher and higher firing rates. Such changes are referred to as neuropathic pain by scientists, i.e., sustained activity in brain and spinal cord pain pathways that long outlast the injurious event that caused them.
Such sustained activities in altered pain pathways have a disastrous effect on the muscles of the body that they activate. What happens is that the sustained activity in the pain pathways is also maintained by the nerve cells exiting the spinal cord (motor nerve cells) that control these muscles. Because of the sustained activity, the affected muscles cells cannot fully relax. They develop contraction spots, shorten, are placed under excessive tension and cannot move comfortably through their normal, full range of motion. The result is chronic pain that comes from these muscles. If it goes on long enough, the joints that they are attached to will also get damaged and also become sources of chronic pain. At this point, all the elements of a full blown chronic pain experience are now in place. Without confronting such a chronic pain situation and taking some kind of corrective action, the chronic pain will continue for months and many times for years.
Is there a way out of this dilemma? There is. It involves a two part solution; first, stopping the affected muscles from continually sending painful messages along their nerves into the spinal cord and second, altering the pain circuits in the spinal cord and brain so that they stop firing continuously.
The first part involves identifying the muscles that have been affected, applying sustained pressure to all of the contraction spots in those muscles using the trapped ball method (detailed in The Book [https://store.bookbaby.com/book/A-Way-Out-Of-Chronic-Pain]) and applying sustained stretches of the affected muscles to relieve excess tension in them and recapture their lost range of motion. The second part involves returning each day to confront the contraction spots for at least two to four weeks to get them to stop their destructive effects on the brain and spinal cord pain pathways. If this can be accomplished, it will give them a chance to change their activity patterns and allow them to heal. Along with their healing, will come relief from the chronic pain.
THE RELATIONSHIP BETWEEN POSTURE AND CHRONIC PAIN-PART 2
HOW TO RELIEVE CHRONIC LOW BACK AND UPPER BACK PAIN BY ADDRESSING POSTURAL DEFORMITIES
The March 2022 blog explained how postural deformities can be underlying causes of back and shoulder chronic pain. The figure illustrates the two most common postural deformities that can affect us as we get older; one affects the lower back and the other affects the upper back.
When we see someone with such deformities, our first reaction typically is, “Oh, this is someone who has spine problems”. There are indeed problems with the spine. However, what caused them was not the spine per se, but the muscles acting on the spine.
In the case of the lower back deformity at the base of the spine, the lumbar curvature has been flattened out and the whole upper body has been pulled forward. The culprits are the abdominal muscles (arrow 1) which have become severely shortened and the victims are the back extensor muscles (arrow 2) which have been put under excessive tension and weakened so that they can no longer fully perform their antigravity function. Existing in this state, the back extensors at arrow 2 are probably full of contraction spots and may have been hurting for some time.
It is easy to see how the act of simply bending forward at the waist to pick something up off the floor would place the back extensors under additional tension and could lead to a sharp pain in the lower back. The way out of this postural dilemma is to lengthen the abdominal muscles at arrow 1 while simultaneously relieving the excessive tension in the back extensors at arrow 2. Eliminating any contraction spots inside the back extensors by using the trapped ball method is explained in detail in The Book. If this, along with lengthening the abdominal muscles, can be achieved, the lumbar curvature can be restored and the potential danger to the joints and disks between the vertebrae of the lumbar spine will be greatly diminished.
There are three ways to lengthen the abdominal muscles. The first way involves lying on your back and placing a rolled up towel under the back of your waist at the level of the belly button. The second way involves lying on your stomach and placing pillows under your chest. The third way involves lying on your stomach, but this time placing the pillows under the tops of your thighs. In each of these stretches, the abdominal muscles are being lengthened while the back extensor muscles are simultaneously unloaded and relieved of excessive tension. The details of these highly effective stretches are shown in The Book.
The second postural deformity shown in the figure involves the neck, upper back and shoulders. The shoulders droop excessively, curl forward and, along with the head, are held too far forward over the chest. In this position, the pectoral muscles (arrow 3) which flex the arms and shoulders forward have become shortened and the neck and upper back extensors (arrow 4) are under excessive tension and full of contraction spots.
Putting any additional demands on these extensors as we do, for example, when we reach forward or try to lift something heavy over our head makes us susceptible to neck, shoulder or upper back injury and pain. The keys to reducing these risks and improving this postural deformity is to lengthen the pectoral muscles, reduce the excessive tension in the neck and upper back extensors and use the trapped ball method to eliminate contraction spots inside these muscles.
A very effective way to stretch the powerful pectoral muscles is to sit on a chair that has been placed inside an open doorway and place both arms on the door frame. The amount of stretch is determined by how far inside the doorway the chair has been placed. While sitting in this position, the pectoral muscles are being stretched while at the same time the neck and upper back extensors have been unloaded and their excessive tension has been relieved. The Book illustrates three variations of this pectoral stretch along with detailed instructions on how to perform them.
By working on the muscles at the levels of arrows 1-4 that are causing these two destructive postural deformities, you can dramatically reduce the risk of a painful injury and relieve any existing neck, shoulder, upper and lower back chronic pain.
IS IT REASONABLE TO EXPECT THAT A THREE PART APPROACH FOR CONFRONTING CHRONIC PAIN WILL BE ACCEPTED BY THE PUBLIC? YES!!! WHY?
This question was at the heart of a dialog I recently had with a trusted colleague about the approach I have presented in my recently published Book entitled, “A Way Out Of Chronic Pain, How It Happened and What To Do About It”.
Her: “The average person will not embrace a three part approach because first, they will not be interested in the neurobiological explanations about the sensation of pain, and second, you are asking too much of them. People want either a simple one-step, one-repetition approach or they want to be told what pill they can take that will immediately cure their chronic pain”.
Me: “I agree that this is exactly what most people want. This is precisely what i would want if I was in the middle of a chronic pain episode.
Me: “However, the problem is, neither one exists!”.
As you may have already discovered in trying to deal with either an ongoing or past episode of chronic pain, it can be very stubborn and persistent. Here is the reason. Any ongoing chronic pain involves much more than what is going on in the affected body part. For example, when there is long standing pain that is coming from a knee, there is much more involved than just the knee. What is also involved is at least one of the muscles that is attached to the knee, the nerves that send information from the knee muscle(s) to the nerve cells in the spinal cord, the nerve cells in the spinal cord that receive this information and the nerve cells in the brain that receive the information from the spinal cord nerve cells. As a result of your long standing knee pain, all of these nerve cells have been altered from the normal way they handle pain inputs coming from the affected knee. My own research has documented some of the ways in which spinal cord nerve cells get damaged when there is a long standing nerve injury. Recent research has documented the many changes that brain nerve cells and their associated glial cells undergo that result in persistent activity in pain pathways from a body part affected with chronic pain. It is these changes in the altered nerve cells that maintain the chronic pain despite what corrective measures we may take at the site of the knee pain.
These neurobiological changes explain why attempts that are directed only at the affected knee can at best only provide temporary relief because they do not address the nerve cell changes that are sustaining the chronic pain. For example, today there are several substances that can be injected into a painful knee or other joint like steroids, hyaluronic acid, platelet-rich plasma or stem cells and these can provide some symptomatic pain relief. However, relief with such injections is usually temporary, typically lasting a few weeks or, if one is fortunate, a few months before they need to be repeated.
In order to have any chance to break the viscious cycle of chronic pain and for an approach to be successful, it has to address the affected joint, the affected muscles as well as the altered nerve cells. This is why a three part approach is needed. The three part approach involves eliminating sites of contraction inside of affected muscles, static stretches to lengthen these muscles and moving these muscles under load through their full range of motion. The details of the approach are presented in The Book [https://store.bookbaby.com/book/A-Way-Out-Of-Chronic-Pain]. For these reasons, once you come to the realization that there is no simple one-step solution to chronic pain, I hope you will embrace that approach because if you do, you at least have a chance for a long lasting solution to a chronic pain episode.