Neck pain and related widespread and complex disorders are prevalent and common in all people.

The neck, a more dominant structure than the low back in terms of health and longevity of an individual, plays a role in the genesis and perpetuation of or prevention of and recovery from many common and prevalent diseases and disorders. The natural process of aging, degeneration and disorders of the neck not only cause neck pain, stiffness and loss of mobility, but they cause a constellation of widespread and complex disorders affecting the functions and health of other vital organs in the head, face, shoulders, arms including wrist, hand and fingers, chest and abdomen and as distantly as those in the legs. In fact, in many settings, there is no distinct boundary between the neck disorders and many widespread and complex disorders.

The representations of the diseases and disorders manifesting the widespread and complex symptoms, manifestations and ailments relating to the neck are as follow:

  • Pain syndromes
  • Myofascial pain syndrome
  • Headaches
  • Sleep disorders
  • Hormonal imbalances
  • Facial pain and disorders
  • Ear, nose and throat disorders
  • Spinal cord diseases
  • Pinched nerves
  • Carpal tunnel syndrome
  • Thoracic outlet syndrome
  • Arm and wrist pain and swelling
  • Tingling, numbness, pins and needles in the arms and legs
  • Weaknesses of muscles
  • Movement disorders
  • Fallings
  • Paralysis
  • Gastrointestinal diseases
  • Heart diseases
  • Blood vessel diseases
  • Stroke
  • Joint diseases
  • Rheumatism
  • Psychiatric illnesses
  • Premature aging and deaths

The contributions of the neck to these disorders are subtle and remain the medical enigmas. The relationship of the neck to these disorders is much more prevalent and common than low back pain and related disorders. However, the former is less recognized than the latter as is not readily appreciated by people and physicians alike. Many physicians and doctors neither know nor understand the sources and causes of the neck ailments and related widespread and complex disorders and, therefore, correct diagnoses are often limited. Because of this limitation, whenever pain or abnormalities require treatments, the ability to care and manage the pain and disorders are limited to a site of symptoms and manifestations and the causes are neglected. Moreover, the uses of drugs, therapies, manipulations and surgery may or may neither be effective nor needed.

PERPLEXION

As a common, prevalent and costly affliction of all people, there was no concerted and universal effort heretofore made to communicate vital information in the prevention, care and management of neck pain and related widespread and complex disorders, suffering and disability. Patients are inundated with inaccurate information. Moreover, information being passed on to the patients may neither address the problem nor base on fact. Consequently, many individuals suffering from the above are misguided. Their families, friends and employers share their emotional anguish and financial strain.

  • Useful and intelligent information is not readily available to people with neck pain and related widespread and complex disorders.
  • Patients are deluged with and confounded by useful and useless opinions, advises, prescriptions, tests, treatments and procedures.
  • Money is spent and wasted as they continue to buy and consume services, products, devices, remedies and drugs that may be useful, useless or, in many instances, even harmful.
  • Costly tests such as MRI, CTScan and electrodiagnosis (EMG/NCV) often add more confusion, dismay and anxiety.
  • After the time for healing has been used and treatments have failed to decrease the pain, suffering and disability, the patients with chronic and recurrent neck pain and a constellation of body and mental illnesses drift toward ineffective or unnecessary procedures including surgery.
  • Desperate, confuse, naïve and vulnerable patients may have to make a difficult and crucial decision to proceed with ineffective or unnecessary procedures including surgery.
  • Essentially, most neck surgeries are the poor alternative to the conservative albeit effective management of neck pain and widespread and complex disorders.
  • Related complications and consequences after surgery are extremely common. Repeat surgeries may be recommended and performed with same consequences.

ESCALATING HEALTHCARE COSTS

  • People, employers, companies, corporations and other payers are spending billions of dollars each year on unnecessary tests and ineffective or even harmful treatments, therapies, care, drugs and devices relating to neck pain and related widespread and complex disorders.
  • Absenteeism, lost wages and productivity are extremely costly to people, employers, companies and corporations.
  • The liabilities and insurance and workers’ compensation costs continue to escalate.
  • The problems are not heretofore widely recognized and, therefore, the solution to the above problems was not in sight.

NECK PAIN IN THE NUTSHELL

The following information helps people to:

  • Understand their necks.
  • Avoid the pitfalls in their searches for the proper care and treatments of neck pain and related widespread and complex disorders.
  • Exercise some control on the decision-making process.
  • Undertake appropriate responses in consultations with their physicians.

The neck is the conduit for the spinal cord, sensory, motor and autonomic nerves shuttling the life force between the spinal cord and the head, face, neck, torso, limbs and organs in the chest such as the heart and lungs, abdomen such as stomach, small and large intestines, pelvis and legs. Similarly, it also houses and protects the great arteries, veins and lymphatic channels conveying blood and lymphatic fluid to and from the neck and head.

The neck supports the head weighing about 1/7 of the total body weight. It is the most mobile part of the spine. It twists, turns and bends over 600 times each hour whether a person is awake or asleep. Moreover, nature has not anticipated the advent of machines and devices such as the automobile and computer and modern activities of daily living such as sleeping on pillows, sports and exercises. Consequently, in addition to the repetitive motions, the neck has to deal with the sudden or chronic repetitive stresses, strains and injuries associate with the uses of the modern machines and devices and activities.

Like the self-limiting LBP, common and benign neck ache and stiffness may be self-limiting and spontaneously resolve. However, without the load on the low back that serves as an early warning signal in low back pain, neck pain and related widespread and complex disorders can be subtle and develop over a longer period of time. Furthermore, neck pain and related widespread and complex disorders are more distressful to patients because they influence or affect the organs of the head, face, neck, chest, abdomen, arms including hands and fingers. In most instances, neck pain and related widespread and complex symptoms, complaints and disorders have far more urgency to be diagnosed and treated due to greater and potentially catastrophic implications.

Whether neck pain and related disorders are sudden or chronic, it heralds in serious or life-threatening conditions. Symptoms and findings such as acute, recurrent, extraordinary amount of pain, stiffness and muscular spasm and loss of movement of the neck, arms and legs are indications of serious problems. Symptoms and manifestations in other body parts such as pain, ache, abnormal eating, swallowing, bowel sensations and movements, urination, sensations such as tingling, numbness, pins and needles and various types of pain sensations in the head, shoulders, arms, hands, fingers, and toes, weakness of the arms, hands, fingers, legs are indications of serious conditions.

Sources and causes of common neck pain

Biomechanical disorders comprise stress, strain and sprain of the soft tissues such as the ligaments, muscles, tendons and discs of the neck.

Like the knee joint, the mobility of the neck such as turning, bending and twisting is possible because of multiple small joints and facets, the short and long ligaments and muscles. These facets and joints are held together and supported by the ligaments, muscles and their tendons. As the neck is the most mobile portion of the spine and repetitively moves more than 600 times each hour, tremendous strain is repetitively imposed on these structures. These frequently occur in people in their ordinary activities of daily living. Consequently, a human’s neck is commonly afflicted by inflammation, pain, muscle stiffness and spasm and loss of mobility and its degeneration occurs with exceptional regularity.

A weakness or imbalance of the ligaments, muscles, tendons, joints and facets leads to their stress, strain or sprain. Usually in common neck pain, a group of related structures such as the ligaments, muscles and joints are stressed or strained at a time. Thus, people with neck pain cannot exactly isolate or pinpoint the structure or structures involved in neck pain.

In young individuals, most neck pain is perceived to localize to neck muscle ache and stiffness. In most instances, the structures have the resiliency to repair, recuperate and recover from the stress, strain or injury. This is a reason why common neck pain spontaneously resolves without any medical intervention.

However, when the ligaments, muscles, tendons, joints and facets are inflamed, neck pain is experienced as ache and pain, muscle stiffness, spasm, rigidity, weakness of the neck causing the loss of mobility of the neck and the widespread and complex symptoms, complaints and disorders. Oral medications usually yield relief and hasten the recovery process.

On the contrary, the degenerative process progresses in older individuals leading to the degeneration and aging of the above soft tissues. Inevitably, arthritis, facet osteoarthritis, weak ligaments, muscles and tendons and vertebral bone and disc occur. In the face of repetitive stresses and strains, the weakened ligaments, muscles and tendons are less able to support the above structures. These structures are prone or more susceptible to stresses, strains and injuries, however minor, and inflammation and pain. Consequently, neck pain and related widespread and complex symptoms, complaints and disorders become more prevalent and common. The range of motion and mobility of the neck are decreased. Deformity of the neck such as spinal stenosis (narrowing of the channels for the nerves and spinal cord), herniated disc and shifting of the spine ensue. In these instances, patients are less likely to spontaneously recover from neck pain and related widespread and complex symptoms, complaints and disorders even with most medical interventions.

In these individuals, the results are recurrent and disabling neck pain involving arthritis, facet osteoarthritis, arthropathy, joint pain, weak and inflamed ligaments, muscles and tendons. The weakened structures further cause a constellation of widespread and complex symptoms, complaints and disorders involving the head, neck, shoulders, limbs, chest and abdominal organs.

Neck strain and sprain are caused by poor neck postures, repetitive motions, sudden movements such as acceleration and deceleration, hyperflexion and hyperextension motions or whiplash injury of the neck. The strain and sprain are commonly encountered in people’s activities of daily living, motor vehicle accidents, fallings and sports. In severe cases, injuries such as contusions and tears of the muscles, ligaments and tendons or even fractures of the vertebrae can occur.

The prolonged, sustained and repetitive motions such as fixing the neck in one position for a prolonged period of time, repetitive turnings and bendings of the neck commonly cause neck pain and stiffness. In addition, people may commonly and prevalently experience widespread and complex disorders such as headaches, poor or disruptive sleep, fatigue, arm and wrist pain, ache, swelling, tingling, pins and needles and numbness. These disorders baffle most physicians including physician specialists.

In addition, poor low back postures commonly impose stress and strain on the neck causing neck pain.

Osteoarthritis commonly progresses over the course of years and is insidious causing recurrent neck ache and stiffness. Repetitive stresses and strains accelerate the progression and exacerbate the condition. Aggressive arthritis can be a result of injuries, inflammation and infections.

The degenerative changes are associated with stiffness and contracture of muscles and soft tissues, hypertrophy of the facets and joints, deformity of the facets, joints and ligaments, drying and degeneration or erosions of the discs and bones also known as spondylosis; protrusion, bulging or herniation of the disc or discs, a break of a vertebral bone also known as spondylolysis; the forward or backward shifting of one vertebral bone relative to the adjacent vertebral bone also known as spondylolisthesis; the impingement or compression of the dural sac or coverings of the spinal cord and nerve roots, and the impingement or compression of the spinal cord and nerve roots.

The degenerative changes of the neck are commonly associated with referred or radiating pain to other parts of the body such as the head, face, shoulders and limbs. In addition, the widespread and complex symptoms, complaints and disorders are common and prevalent.

For example, the cervical or neck facet syndrome is caused by the degeneration of the neck facets or joints. It comprises radiating, referring or shooting pain to back of the head, face, shoulders, chest and arms, wrists, hands and fingers. Other associating abnormal sensations include ache, swelling, tingling, pins and needles, numbness and abnormal skin temperatures and colors.

The severe degenerative neck of a person commonly associates with a jutting head and rigid posture.

Myofascial pain syndrome or fibromyalgia is common and prevalent. It afflicts all people. Detailed information is in Enigma Unraveled.

Essentially, myofascial pain syndrome or fibromyalgia is mediated and propagated by the sensory and autonomic nervous systems. It comprises inflamed and hyperirritable nerve endings, muscles, tendons, bursae and fasciae also commonly known as trigger points or acupuncture points, fibrositis, myofascial pain, tendonitis, bursitis and fasciitis.

Myofascial pain syndrome comprises a widespread and complex pain, symptoms, complaints and disorders such as varying degrees of sharp, lancinating, dull, achy, burning, throbbing and miserable pains, weakness and abnormal or unpleasant sensations such as tingling, pins and needles and numbness in the back and legs. Headaches, face, neck, shoulder and arm pains are common and prevalent. Patients often cannot lie on the pain side of the neck or body. Weakness or heaviness the neck, shoulders, arms, wrists and fingers causes dropping of objects such as pen or pencil and kitchen utensils. Swelling of the face, neck, arms, hands and fingers are common. Poor sleep, gastrointestinal and hormonal disturbances are common.

Repetitive strain injuries or cumulative trauma disorders are common and prevalent among people such as workers or athletes engaging in repetitive motions or prolonged fixation in a position of the neck. The duration of the activities can be brief or long. For example, workers in non-ergonomic work stations such as cash register and computer operators and train conductors who repetitively turn their heads, and dentists and dental assistants whose necks are bended during the time they are working.

In these patients, neck pain and stiffness and the aforementioned widespread and complex disorders inevitably occur. These disorders baffle most physicians including physician specialists.

Cervicogenic headaches or headaches which are caused by the inflammation and disorders of the neck structures are common and prevalent. The figure shows each site or sites – one red dot or multiple dots – that can be involved in the cervicogenic headaches and related disorders.

Anterior scalene syndrome is caused by the compression of the nerves in the neck by the anterior scalene muscle. There are also pain, numbness, tingling, loss of sensation and weakness of the arm including hand and fingers.

Claviculocostal syndrome or thoracic outlet syndrome is caused by the compression of the nerves, arteries and veins by the first rib and collarbone (clavicle) at the top of the front chest. The symptoms are pain, numbness, tingling, pins and needles, coolness and discoloration of the arm, wrist, hand and fingers.

Non-mechanical causes of neck pain are relatively less common but may have life-and-death implications. Therefore, it is imperative that the patients urgently seek medical care of their physicians.

Infections can be caused by bacterias, viruses, fungi and parasites such as staphylococcus, E. Coli, tuberculosis, herpes zoster, coccidioides immitis, syphilis, Lyme disease and Echinococcus granulosus (tapeworm).

Primary or local cancers can occur from the neck tissues. Some of these cancers are hemangioma, lymphoma, chordoma, osteoma, sarcoma, Padget’s disease, giant cell tumors.

Metastatic cancers can spread from the cancers of the breast, lung, prostate, thyroid, kidneys, stomach, uterus, multiple myeloma or non-Hodgkin’s lymphoma.

Rheumatoid arthritis (RA) affects the neck. The most feared complication of RA is the atlantoaxial dislocation (Atlas, the first neck vertebra, shifting away from the Axis, the second neck vertebra) which can cause paralysis of the arms, legs or all four limbs and death. In the patient with RA, the symptoms are neck pain and stiffness, head pain, sharp radicular pains radiating to the shoulders or arms, paresthesia (abnormal sensations such as tingling and pins and needles) in the hands. Associate with the above symptoms are decreased touch and tactile discrimination of the hands and fingers, slow progressive spastic quadriparesis (weakness of all four limbs) and painless loss of sensation in the hands and/or legs, abnormal urination and urinary bladder function.

Ankylosing spondylitis is a chronic inflammatory arthritis of unknown cause. Infections, trauma and genetic predisposition are thought to be involved. Neck involvement is less frequently than low back involvement and at a later time in the course of the disease.

Downs syndrome is a genetic disorder that can also cause atlantoaxial dislocation (Atlas, the first neck vertebra, shifting away from the Axis, the second neck vertebra) which can cause paralysis of the arms, legs or all four limbs and death.

Diffuse idiopathic skeletal hyperostosis is the calcifications or hardening of the ligaments of the neck. Symptoms include neck pain, stiffness and perhaps dysphagia (difficulty in swallowing).

Metabolic diseases such as osteoporosis, osteomalacia, Paget’s disease and Kummel’s disease can also cause neck pain.

Neuropathy, Radiculopathy and Radiculitis comprise ailments and diseases afflicting the nerve in the neck. They occur in many diseases such as those mentioned above, aging, arthritis, arthropathy, diabetes, cancers and alcohol.

Widespread and complex symptoms and findings
Referred disorders including pain have their sources in the neck and is also experienced or perceived in other distant parts of the body. Most common targets of the disorders are the neck itself, head, face, chestwalls, organs of the chest, abdomen and pelvis, shoulders, arms, wrists, hands and fingers.

Some common symptoms and findings

  • Headaches
  • Poor or non-restorative sleep, insomnia and fatigue
  • Face pain
  • Arm, hand and finger pain, stiffness, heaviness, weakness, locking, swelling, tingling, pins and needles, and numbness
  • Poor arm and hand coordination
  • Weakness of the arm, hand and fingers causing dropping of hand-held object
  • Front and back chest pain, breathing difficulty, asthma-like breathing problem
  • Gastrointestinal problems such as loss of appetite, indigestion, gas, bloating, intestinal motility problems, irritable bowel, constipation, diarrhea
  • Bladder problems such as urinary retention, poor control of the urine and the need to go frequently to urinate

CORNERSTONE OF MANAGEMENT OF NECK PAIN

CAUTION: You must consult and see physicians skilled in the diagnosis and treatment of neck pain and related disorders (NP). The information herein and related work only serve to inform and nothing more.

    • Delayed seeing, diagnosis and proper treatment of NP by competent physicians pose an increase risk and complication of an illness that can become a life-or-death matter.
    • NP is extremely complex, insidious and can be serious

.The means for preventing and treating NP and the means for realistically curbing the escalating healthcare costs can only be effectively applied in a team approach comprising:

  • Well-informed, educated and complaint patients.
  • Skilled physicians, massage therapists and exercise physiologists.

Well-informed, educated and complaint patient plays a crucial role in the management of NP. Patient can give accurate and reliable history including the cause, assist in the physical examination and, of course, complying with the care, treatments and management NP. Ultimately, patient decides the outcomes of a good program of care and management of NP.

The clinicians are endowed with different skills and varying and diverse abilities and expertises to treat and care for NP. The cornerstone of the effective management of NP comprises:

  • The effective ongoing program of maintaining the health and optimal condition of the neck and shoulders.
    • Education, constant reinforcements and compliance being performed and concerted efforts of patients themselves.
    • The biomechanics of the neck and shoulders.
  • The expeditious and effective diagnosis, treatments, whenever necessary and indicated, and support by skilled and knowledgeable physicians and therapists.

In tens of thousands of patient cases, the head, neck, shoulders and arms served as the crucible for the data supporting the current medical approach.The effective management of neck pain and related disorders (NP) is complex and requires skilled physicians with expertise in many disciplines. Expert, not unlike an Emperor ruling a far-flung empire, has the experience and skill to recognize the simplicity and complexity of NP and can choose and tailor the treatments and management suitable for NP of an individual. A physician’s accurate diagnosis leading to the effective care, treatments and management result in the good outcomes. A skilled physician with excellent knowledge of human anatomy expertly performs the treatments resulting in fast and early recovery.

Effective treatments

Always consult your physicians before acupuncture medicine to determine if acupuncture medicine is the appropriate treatment or the treatment of choice.

Acupuncture Medicine is scientifically supported by several recent scientific studies, numerous clinical reports and the extensive researches performed by this writer. With correct diagnosis by a physician, acupuncture is very effective, if not the most effective, anti-inflammatory electro-therapeutics for treating acute and chronic low back pain and related disorders.

Aside from the above, acupuncture medicine is an excellent anti-inflammatory therapeutics in lieu of oral and injectable drugs such as the nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naprosyn and ketolorac and the steroids such as prednisone. In many of the above NP and settings, NP is not responsive to oral or injectable drugs.

Moreover, most seniors and some people have the following concerns:

  • Risks of gastrointestinal irritation and bleeding
  • Intolerable or adverse side effects such as vomiting, dizziness and weakness
  • Drug allergy
  • Drugs adverse interaction
  • Ineffectiveness of the medications
  • Appropriate care in lieu of surgery
  • Surgery is not an option

In the hands of a skilled physician who is an expert in human anatomy, acupuncture medicine is very safe and almost always painless. The relief from NP may be immediate.

Trigger point injection in myofascial pain syndrome is performed by many skilled physicians throughout America. This routine procedure involves the use of a small and thin needle to safely inject a small quantity of local anesthetics such as lidocaine solution into the painful trigger point or site. In the hands of the skilled physician, the trigger point injection is very safe and almost always painless. The resolution of pain and associate symptoms may be fast and remarkable.

Similarly, tendonitis, tenosynovitis and bursitis in the neck, shoulders and arms can also be treated by local anesthetics to obtain similar relief.

Acupuncture medicine and local anesthetics are synergistic in action. In other words, both give relief from pain and associate disorders.

Oral medications comprise various medications that are used singly or in combination. A physician’s accurate identification of the sources and causes of NP and the diagnosis allow the efficacious use of medications resulting in corresponding response and the relief from NP, the improvement of the function and speed up recovery.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) are the most commonly prescribed and consumed by patients with NP. Some common drugs are Aspirin, Motrin, Naprosyn, Relafen, Daypro, Celebrex, Dolobid, Trilisate, Ansaid, Daypro, Indocin, Clinoril, Lodine, Feldene and Toradol. A common side effect is irritation and pain of the stomach.

Acetominophen or Tylenol is used with varying success and degrees of relief. Long-term use can cause liver toxicity.

In certain circumstances, the muscle analgesics and relaxants are used with varying success and degree of relief. Soma, Parafon Forte, Flexeril, Robaxin and Valium are common drugs. Side effects include drowsiness and weakness which are not well tolerated especially by seniors.

Narcotic analgesics are used with varying success and degrees of relief. Codeine and percocet are the two common painkillers. Side effects such as drowsiness and weakness are not well tolerated especially by seniors. Furthermore, the limitation to use is the anxiety of patients and physician of the tendency to the drug addiction.

Antidepressants in low doses can be used for management of NP. Amitriptyline, Nortriptyline and Desipramine are some of the commonly used drugs. Side effects such as drowsiness and weakness are not well tolerated especially by seniors.

Steroids by mouth or by injection such as prednisone are commonly used. The limitation is the side effects on the natural hormones of the body and body metabolism. In most NP, epidural steroids comprising the injection of steroids into the epidural space of the spinal cord are ineffective. However, a skilled physician can usually determine the type of NP that may be responsive to epidural steroids.

Massage therapy in a team-member setting, a skilled massage therapist can identify and treat the musculoskeletal spasm, stiffness and contracture. Thus, a skilled massage therapist significantly contributes and effects the good outcomes in the care and treatments of NP.

The massage therapy usually comprises the mobilization of soft tissues, release of myofascial and trigger point, stretching and balancing the muscles and tendons and the release of soft tissue contracture.

Exercise physiology is vital to the health of the neck. In most circumstances and settings, good postures, ergonomic movements and positions of the neck, shoulders and torso, healthy and strong ligaments, muscles and tendons of the neck and shoulders can prevent and treat NP.

A skilled exercise physiologist as a team member, with the physicians and therapists, can significantly contribute to the good outcomes.

The exercise regimens include proper cardiovascular conditioning, muscular toning, conditioning, strengthening and stretching of the shoulders and arms.

Repetitive turnings, bendings and twistings of the neck as a purported form of exercise of the neck muscles may cause more harm than good to the neck.

Always consult your physicians including your heart physicians before participation.

Nutrition

Obesity or excess body weight imposes stress and strain on the low back and neck spine and its vital structure and may indirectly contribute to NP.

In most settings, in conjunction with the above, a balance caloric expense and intake and good nutrition ensure the health and optimal conditions of muscles, tendons, joints, nerves, and bones.

Always consult your physicians including your heart physicians before participation.

NECK PRODUCTS

Furniture such as a chair or a seat affects the postures of the neck. Therefore, the use of ergonomic furniture is important.

Bed and pillow not only affect the postures of the low back and legs, but also those of the neck and shoulders. A firm and supporting bed and the use of proper-sized pillow to support the neck are important. In other words, the neck should not be suspended in the air when the head is resting on the pillow. The neck should be in full contact with and comfortably resting on the pillow on which the head rests.

Soft neck brace or collar is readily available in most pharmacies in America. It is useful in supporting to the neck and giving minor relief to NP. In application, both Velcro ends of the collar should engage each other and be in front of the neck. It can be applied to the neck while the person is in and out of the bed. The neck is supported by the collar during sleep. Other types of neck braces should be obtained through your physician.

Gel supports, cushions, insoles and footwear can significantly reduce the forces being transmitted from the ground to the back and then into the neck.

In the industrialized nations, in general, people walk on or pound the concrete and hard ground or surfaces with their feet such as the streets and floors in the homes or offices. Therefore, people should use these devices as the foremost, inexpensive and cost-effective passive means for reducing the stress and strain on the back and neck.

Generally, most brands of running sneakers are well designed for absorbing the impact from the ground. On the contrary, well-designed dressed shoes for absorbing the impact from the ground are uncommon.

A physician who treats low back and neck pain or some podiatrists can advise the patients on the use, applications of and indications and the sources for acquiring gel supports, cushions, insoles and footwear.

Mechanical neck stretcher should be used only under the supervision of your physician. In some cases, it may be useful.