How the ravages of history launched two profound professions

Posted 4/20/2022

When a doctor recommends occupational therapy (OT), rather than physical therapy (PT), many people don't at first realize there are two kinds of therapies.

It might also not be understood that there's a difference between them, or why a doctor prescribes one over the other.

As therapists, we get this question a lot.

For sure, there's a difference between the therapies and how they're used in healing and recovery. And the story is more interesting than you might imagine…

A short history of modern therapy

Movement and manual therapies can be traced back to ancient Asia, Greece and Rome. Those early practices included massage and hydrotherapy (water therapy).

Fast-forward to modern-day therapy which began in 18th century Sweden with the practice of orthopedics — the medical focus on bones and muscles.

A bit later, Hanrik Ling, developed the Swedish Gymnastic System (also known as the Swedish Movement Cure). His motivation? Having experienced the benefit of improved body movement through his practice of fencing.

At its core, Ling's system emphasized physical conditioning for its ability to improve health and body function. It combined lesser intensive floor-style of gymnastics with manual therapy. Ling's approach brought wide acceptance of his methods.

In 1813, the Swedish government appointed Ling to start the Royal Central Institute of Gymnastics (RCIG).

Ling's system became wider spread as graduates of the RCIG adopted its four core components:

• physical education
• fencing
• massage, physical therapy, physiotherapy
• dance performance

One more fast-forward to the 1920s. The polio epidemic was raging in the United States, especially among children.

During the epidemic, two schools of thought emerged.

One used the practice of immobilizing the limbs of patients believing limb movement and stretching would impair muscle recovery and cause more deformity.

A second practice re-introduced the Roman practice of hydrotherapy. Here therapists used exercise in heated pools to improve a patient's muscle recovery and movement.

Polio paralysis spurred working with patients to improve balance and regain muscle strength. The benefit of warm water was helpful as well as buoyancy – water supports body weight and reduces stress on the joints.

The practice – active polio therapy – helped grow a population of physical therapy (PT) specialists who became instrumental in treating polio paralysis.

These early PTs developed methods for assessing and strengthening muscles – methods still used today.

This piece of history gave the push to establishing the profession of physical therapy in the U.S.

Turning now to the topic of occupational therapy (OT), its history doesn't stretch back as far as those of physical therapy.

But its roots in America began to grown in the late 1800s. This happened primarily as a way to help individuals with mental illness by engaging them in meaningful tasks. Examples include gardening, painting and arts and crafts creation.

The U.S. military also began recognizing the importance of mental health services for wounded and traumatized soldiers to help them resume daily living.

This marked an entry for OT services in the treatment of individuals with mental and physical needs.

Three movements of thought were significant in the development of OT:

1. The consensus that mental health patients should be treated and not put in asylums or prisons.
2. The reemergence of the value of manual occupation and vocational skills over mass production.
3. The rise of thought that working with your hands to produce items of value can be beneficial to a person’s overall health.

During this time, mental health asylums changed to reflect these new ideas. They were ideas of humane rehabilitation and included craft and recreational activities to help patients return to society through their contributions.

These ideas were foundational for developing OT.

About 1915, a social worker named Eleanor Clark Slagle started the first formal OT education program at John Hopkins University in Baltimore.

Dubbed the "mother of occupational therapy" she trained more than 4,000 therapists and promoted OT within the medical community.

While PT and OT therapies were in their infancy on the two sides of the Atlantic, it was America's entry into the Great War in 1917 where they came together.

To summarize some of the above timeframes, it's worth a look at how it happened.

World War I and its transformation of therapy

World War I transformed medicine and contributed to the development of today's scope of medical care. 

The total number of military and civilian casualties in World War I was about 40 million.. and about 23 million wounded military personnel.

– Wikipedia

With the staggering number of wounded worldwide, orthopedics and therapists rapidly advanced to meet the need.

The course of thought was that society had a moral responsibility to help these soldiers return to a normal and purposeful life. Thus, medical specialties developed to fill this need.

The U.S. military hired a small group of women, calling them "reconstruction aides." In their roles they provided treatment by teaching occupation skills to the wounded. 

The initial 18 aides were trained in the latest European physiotherapy practices at the time. Aides were chosen from civilian women and women from the newly established profession of OT.

Both therapy groups expanded rapidly to help the soldiers with recovery.

Of the original 18 Aides, 16 went on to form the American Women's Physical Therapeutic Association. This later became the American Physical Therapy Association with McMillan as president.

– The U.S. World War One Centennial Commission.

The work of these aides brought the military to begin seeing disability in terms of capability in function, and not as limitation.

Their successes were many, helping wounded soldiers learn to walk again and freely move about in their environments.

These early therapists gave training in the use of arm prosthetics, adapted home and work spaces and taught crafts and vocational skills for mental diversion and future employment.

The convergence of today's therapies and practitioners

After WWI, occupational and physical therapy continued to advance.

And with their evolutions came recognition for the benefits they each provided.

But sometimes there was division in which to prescribe: occupational therapy vs physical therapy.

What became clear over time, with advances in the professions, is the benefit to individuals when providing therapies in tandem.

Today's occupational and physical therapists work together in the shared goal of improving an individual’s function through movement.

As individual medical treatments, the therapies, when used together, can have profound results.

Because of this they are recognized as separate but symbiotic professions.

Similarities include:

Working in a variety of settings

• Schools
• Outpatient rehabilitation centers
• Home health agencies
• Hospitals
• Nursing homes

Training in key disciplines

• Science
• Anatomy
• Kinesiology

Using similar therapy techniques

• Soft tissue mobilization
• Functional activities
• Strengthening
• Stretching
• Pain relief

Opposites attract, even in medicine

Even with similarities between the two professions, there are also key differences.

Physical therapy focuses on improving movement, flexibility and mobility. This includes improving physical motion required for a task.

Physical therapy has a unique approach to mobility – movement and muscle balance. It uses prescribed treatment techniques to maximize function, capacity and performance.

PTs work with patients before and after surgery to build strength and kick-start healing. Therapy uses movement to reduce pain, recover from an injury and promote balance to reduce the risk of falls.

The occupational therapy profession has a different focus.

That focus is on functional ability – the ability of an individual to do activities, work and tasks that are normally performed in everyday living and occupation.

That focus gives occupational therapy its name.

Occupation is defined as an activity that is meaningful and purposeful to the individual. It can include basic activities such as dressing, bathing or fixing a meal.

It can also include specific activities which are unique to the individual.

For example, you may be a high school teacher, home gardener, pianist or an electrician. Each occupation requires a unique set of activities. If those activities are compromised by illness or injury, OTs can help.

Your therapist will assess your current function and how to improve your ability to perform a task or modify it to help you complete it.

Now that you know more about the differences between OT and PT, should you need therapy you'll be able to spot the differences in what your therapist recommends.

Of course, it all depends on your condition, your needs, and personal goals.

But thanks to a long history of the disciplines, and more than a century of experience since WWI, PTs and OTs are specialists in your care.

Our job is to help get you back to enjoying the activities that matter to you.

If you or someone in your family might benefit from our therapies, request an appointment with us. We're here to help.

Posted on 3/9/2021

PODCAST: The Best Treatment for Patellar Tendonitis

RUSH Physical Therapy’s Joshua James, DPT, CSCS, recently joined Dr. Brian Cole, orthopedic sports medicine surgeon, and Steve Kashul, host of Chicago Bulls Basketball, on Sports Medicine Weekly to discuss the best ways to manage and treat patellar tendonitis, more commonly known as jumper’s knee. Check it out!

More information can also be found at sportsmedicineweekly.com.

 

Posted 2/25/2022

How to stay in play and on the court

What is pickleball? And why are people raving about it?

Pickleball is an improvisation of badminton and ping-pong. The game is played on a court using a softball-sized, hard-plastic ball with holes – like a wiffle ball – and paddles similar to table-tennis paddles.

Conceived in 1965 as a game that families could play together, pickleball grew in popularity. By 1972, a corporation was founded for the sport.

While there is debate around the origin of its name, there is none about how fun, fast, competitive and entertaining the game is.

With a smaller court size than its cousin sport of tennis, it’s an ideal way to stay active and fit for just about anyone.

And pickleball has taken the country by storm.

The first pickleball tournament was held in 1976 in Washington State. And while not what’s called an overnight sensation, the explosive growth of the game in the years since has led to pickleball courts popping up everywhere, and the formation of amateur and professional leagues.

There’s even a professional pickleball tour.

When injury puts you in a pickle

With the rise in popularity of pickleball, physical therapists throughout the country are seeing an increase in injuries that are similar to those found in other racquet sports.

New pickleball players sustain approximately 50% of injuries during their first year of play.

The most common pickleball injuries include:

• Pickleball elbow
• Ankle sprains
• Knee sprains
• Shoulder sprains
• Achilles tendonitis
• Wrist fractures
• Concussions from falls

In the case of older players, many are predisposed to injury, often due to prior injury, limited flexibility and range of motion and deterioration of balance, or have recurrent injuries.

So if you are looking to start playing the game … or stay in the game … keep these prevention tips in mind to reduce your risk and avoid injury:

Warm up   Pickleball is a fast-paced game, and the excitement starts right away. So it's important that you warm up before you get on the court. Try a light 5-minute jog, a slow walk with high knees or some side shuffles to loosen up.

Stretch   As part of your warm-up, make sure to stretch. Shoulder stretches, calf stretches, hamstring/quad stretches and wrist and neck stretches are all important to incorporate into your routine.

Choose proper footwear   Pickleball requires moving side to side and back and forth. Choose a good fitting athletic shoe for this type of movement.

Pivot   Similar to tennis and other racquet sports, you will be executing groundstrokes, volleys and serves. Remember to pivot your hips and shoulders as you face the approaching ball.

If you are injured, stop playing!

Don’t try to tough it out, especially if it is a head injury.

Contact a physical therapist to help you heal and recover before you return to play.

Pickleball is as fun as it sounds, and you’ll want to play for years to come.

If you’re in a pickle with pain or injury of any sort, click now to request an appointment to find one of our centers near you.

NovaCare and RUSH Physical Therapy are part of the Select Medical Outpatient Division family of brands.

Select Medical is proud to be the official physical therapy partner of the PPA Tour.

Posted 2/15/2022

If you clicked to read this, it’s likely because you or someone you know has long COVID. Or maybe you’re now hearing people talk about long-lasting symptoms of COVID-19.

With research now being published, millions of people having a COVID diagnosis will experience “long” COVID – post-COVID syndrome or long-haul COVID, earning some who experience it the nickname of “long hauler.”

Putting aside that bit of levity, long COVID is no joke.

So if you are struggling to read this because you’re dealing with “COVID brain fog,” you may be thinking, How did I get so unlucky?

It’s a fair question to ask.

But in reality, long COVID is more common than most think.

According to Penn State College of Medicine researchers, more than half of the 236 million people who have been diagnosed with COVID-19 worldwide since December 2019 will experience post-COVID symptoms.

Months after recovering from COVID-19, millions of people are still suffering one or more debilitating symptoms like:

• Brain fog
• Difficulty breathing
• Muscle weakness
• Fatigue
• Joint pain
• Dizziness and more

If you or a loved one is suffering, don’t give up. There is hope and help.

Physical therapy is medicine for long COVID

Professional physical therapists, like me, understand what you are going through. Indeed, if you have long COVID, physical therapy can help.

Yes, physical therapy.

As physical therapists, we are specialists who are trained in identifying the clinical symptoms and effects of long COVID. For example, the profound fatigue you’re feeling? Reminiscent of chronic fatigue syndrome, it’s a post-acute leftover of the viral COVID infection, and we can help.

That joint pain? We’re trained also to understand musculoskeletal conditions that can be causing your pain. We can assess the pain and determine the appropriate treatment for it.

I work in an outpatient physical therapy center and help treat patients with long COVID. Our parent company Select Medical collaborated with the Centers for Disease Control and Prevention on an important clinical study regarding the long-term impact of COVID-19.

The study validates our Recovery and Reconditioning program which focuses on specific deficits in patients recovering from COVID-19 and other debilitating illnesses and conditions.

Our Recovery and Reconditioning program helps, specifically, with:

• Fatigue
• Labored breathing
• Weakness
• Headache
• Dizziness
• Joint and muscle pain

Our program was developed in partnership with leading physicians, infectious disease specialists, physical and occupational therapists and speech-language pathologists to help those impacted to heal, gain strength and return to an active, full lifestyle.

We hear all the time that people suffering with long COVID don’t feel heard. Feel misunderstood. Feel like giving up.

If that sounds like you, then trust me, we understand.

We are proud to offer the Recovery and Reconditioning program to you, your loved ones and/or friends – anyone who may be dealing with lingering effects of having COVID-19.

Together, we will address your specific post-COVID symptoms and create an individualized treatment plan for your road to recovery. During care, you will learn ways to pace yourself throughout the day and move your body so that you don’t tire so quickly.

As part of your treatment, we will track your vital signs and symptoms to ensure your safety and progress. We will be there every step of the way back to a healthier you.

You deserve a medical professional who understands you. If you’re tired of feeling alone in your recovery from long COVID, let a physical therapist help.

Schedule a consultation with a physical therapist trained in treating long COVID. Click the blue Contact Us button below to request an appointment at a center near you today.

By: Corey Malone, P.T., DPT, OCS. Corey is physical therapist, center director and Recovery and Reconditioning program champion with KORT in Kentucky.

KORT and RUSH Physical Therapy are part of the Select Medical Outpatient Division family of brands.

Posted on 1/20/2021

PODCAST: Maximizing the Squat Exercise

RUSH Physical Therapy’s Dustin Jesberger, P.T., DPT, recently joined Dr. Brian Cole, orthopedic sports medicine surgeon, and Steve Kashul, host of Chicago Bulls Basketball, on Sports Medicine Weekly to discuss maximizing the squat exercise. Bodybuilders, powerlifters, athletes and those simply looking to get into shape can all use the squat to achieve their fitness goals. Check it out!

More information can also be found at sportsmedicineweekly.com.

 

Posted on 12/8/2021

PODCAST: The Benefits Of Yoga For Athletes

RUSH Physical Therapy’s Lesley Bezdek-Cohen, P.T., DPT, recently joined Dr. Brian Cole, orthopedic sports medicine surgeon, and Steve Kashul, host of Chicago Bulls Basketball, on Sports Medicine Weekly to discuss the benefits of yoga for athletes. Lesley danced professionally with ballet and jazz companies prior to becoming a physical therapist and has been teaching yoga since 2009. Check it out!

The podcast is now available to stream on Spotify, Apple Podcasts or wherever you enjoy your podcasts. More information can also be found at sportsmedicineweekly.com.

 

Posted on 10/25/2021

Did you know that knee osteoarthritis affects nearly 14 million adults in the United States¹ per year? Or that meniscus tears are present in 60-90%¹ of those with knee osteoarthritis? With symptoms ranging from knee pain, swelling, stiffness and limited range of motion, medication, injections, surgery and physical therapy are all commonly prescribed to manage knee pain. Medication and injections, however, may simply serve to mask your pain. Surgery can be costly and taxing on your body. Physical therapy, on the other hand, emphasizes a more holistic approach to the body with emphasis on education, pain management and strength and conditioning.

At first glance, it can be frustrating when you are referred to physical therapy for management of knee pain related to structural issues like osteoarthritis or a knee joint tear. Is the physical therapist going to magically reverse your arthritis or heal your meniscus? Shouldn’t you address the structural problem head-on instead of just “strengthening around it?”

Not necessarily.

Surgery or osteoarthritis physical therapy?

If we dig deeper, a better question to consider might be, “Do I need to change the structure of my knee in order to resume the activities I enjoy?” There are several studies to suggest that abnormal findings on X-rays and MRIs can be common, even in persons without knee pain. In fact, a 2020 study² of a population with a median age of 44 and no knee pain found that an astounding 97% of knees had abnormalities on MRI. In addition, when comparing physical therapy management to surgical intervention, there are many cases with similar outcomes.

Now, this is not to say that everyone with knee pain should get physical therapy instead of surgery. Sometimes, surgery is exactly what’s needed to improve your overall quality of life. However, including a physical therapist on your health care team – before and after surgery – is beneficial, even without changing the structural abnormalities that are often presumed to be the problem.

If physical therapy isn’t changing the “structural problem,” what exactly is the benefit?

People are more than pictures, and pain is far more complicated than what that picture shows. X-ray and MRI findings can absolutely be helpful in developing a plan of care; however, they are only one piece of the puzzle. While physical therapy is unlikely to result in a change in the X-ray or MRI findings, it can identify and help modify factors contributing to your knee pain and functional limitations.

Focusing on your unique condition, a physical therapist can work with you to determine the following:

• Health and lifestyle factors contributing to your knee pain
• Activity modification so you can safely perform activities of daily living
• Stretches and strategies to improve motion and strength
• Swelling and pain control
• How and when to appropriately get back to activities that cause you pain/discomfort

This combination can help patients to better understand their condition and develop a plan that assists in recovery. Doing all of this may greatly enhance your quality of life and ease the pain and symptoms you are currently experiencing.

Now, if you and your doctor determine that knee surgery is necessary, remember, physical therapy is a vital part of preparing for your procedure and recovering after it. Before surgery, we will work together to get you as healthy and strong as possible, which will enable your post-surgical recovery to be that much more successful and faster. Following surgery, we will focus on helping you to restore your strength, balance and flexibility.

No matter what, physical therapists are committed to helping you be as mobile, independent and pain-free as possible. Our goal is to build a relationship in which you feel comfortable asking us questions, are an active partner in your care and we’re able to work together to ensure the best outcomes possible.

If you have knee pain, contact us today and experience the power of physical therapy.

References:

1. Bhushan R. Deshpande, BS, Jeffrey N. Katz, MD, MSc, Daniel H. Solomon, MD, MPH, Edward H. Yelin, PhD, David J. Hunter, MBBS, PhD, Stephen P. Messier, PhD, Lisa G. Suter, MD, and Elena Losina, PhD. The number of persons with symptomatic knee osteoarthritis in the United States: Impact of race/ethnicity, age, sex, and obesity (2017)
2. Horga, L.M., Hirschmann, A.C., Henckel, J. et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol (2020)

By: Patrick Smith, P.T., DPT. Patrick is board-certified clinical specialist in sports physical and orthopedic physical therapy, a fellow of the American Academy of Orthopedic Manual Physical Therapists and a treating physical therapist with NovaCare Rehabilitation in Philadelphia, PA.

RUSH Physical Therapy and NovaCare are part of the Select Medical Outpatient Division family of brands.

 

Posted on 10/1/2021

At RUSH Physical Therapy, we believe movement is medicine. So, what moves you? Physical activity is key to good health, vitality, energy, strength and might even make you laugh more.

If pain or a medical condition is holding you back, we’re here to help. Physical therapy is a moving experience.

Physical therapy gets you back to life and the things that are most important to you. Whether it’s running a marathon, playing with the grandkids or simply cooking dinner pain-free, the benefits of physical therapy can change lives for the better.

That’s why we’re excited it is October, one of our favorite months of the year. Why, you may ask? October is National Physical Therapy Month. For 31 days, we get to celebrate all things physical therapy and the many ways our dedicated physical therapists and physical therapist assistants help improve the quality of life.

There is so much to share about the benefits of physical therapy, including the highly-trained clinicians who provide it. Did you know that physical therapy helps people manage pain and chronic conditions? How about the power of physical therapy to help heal from recent injury and reduce the risk of future injury? Or prepare the body for surgery and successful recovery or avoid the need for surgery altogether? Well, physical therapy does all this and more.

Physical therapy is also a safe alternative to taking prescription medication. It treats common aches and strains, sprains and fractures, and helps with many other issues and conditions, including:

• Back sprain/strain
• COVID-19 fatigue and other debilitating illnesses
• Headaches and concussions
• Vertigo, dizziness and balance
• Disc injury and pinched nerves
• Rotator cuff tear, bursitis and frozen shoulder…and more

So, what moves you? That marathon? Those grandkids? That culinary masterpiece? Whatever it is, physical therapy, and our compassionate team of licensed therapists, can help get you moving.

Request an appointment today and see how physical therapy can physically, emotionally and mentally enrich your life.

#ThePowerOfPhysicalTherapy #WhatMovesYou #ChoosePT

 

Posted on 9/22/2021

Sports and exercise are part of the lives of many young individuals. Typically, people who participate in sports are known to be healthier and less likely to partake in outside negative distractions compared to people who do not play sports. However, for some adolescent girls, when they only focus on the sport and not their bodies, consequences can arise. 
Many girls who participate in sports are at risk for an issue called the female athlete triad. This triad consists of three conditions, and the athlete can have one, two or all three. The three conditions include disordered eating, amenorrhea and osteoporosis.

Disordered eating

Disordered eating is a term that refers to an individual having unhealthy eating behaviors and worrying about body image. Some of the most common forms of disordered eating include extreme dieting and restrictive eating. On the top end of the spectrum are eating disorders, which involve things such as self-induced vomiting, binge eating and laxative abuse. An individual can have disordered eating and not be diagnosed with an eating disorder. Most girls with disordered eating are trying to lose weight to help them improve their athletic performance. For these specific athletes, this eating pattern can range from not eating enough calories to sustain the amount of activity that they are participating in, to trying to avoid “bad” foods, all the way to eating disorders such as anorexia nervosa and bulimia nervosa.

Amenorrhea

Amenorrhea is the lack of menstruation, or one or more missed menstrual periods. Women who have missed at least three menstrual periods in a row have amenorrhea, as well as girls who have not started their periods by the age of 15. Intense exercise accompanied with not eating enough calories can lead to a decrease in the hormones needed for menstruation. As a result, a girl’s period may never come, become irregular or stop altogether. Some girls who have been participating in sports since a young age may never get their first period, because they have been training so hard. On the other hand, some girls may have gotten their period, but it disappears as their training intensifies or their eating habits change. On one hand, dysfunction of the menstrual cycle can lead to infertility. And on the other hand, it can lead to unplanned pregnancies in young women recovering from the triad. While the cycle is being restored, an egg may be dropped early and, without contraception, pregnancy can occur.

Osteoporosis

Osteoporosis is translated as porous bone. It is a disease in which the density and quality of the bone are reduced. For people with osteoporosis, boss loss overtakes the growth of new bone. Consequently, over time the bone becomes more porous and fragile, and the risk of fracture greatly increases. This typically happens silently, and there are usually no symptoms until the first fracture occurs. In girls with the triad, estrogen is typically lower. Low estrogen accompanied with a poor diet, especially low calcium, can lead to osteoporosis. During the teen years, a lot of bone growth is supposed to happen and the peak bone mass should be reached. An athlete with the female athlete triad will have a hard time getting to her peak bone mass, and it can affect her greatly later in life.

Takeaway: Diagnosing and treatment

Girls who have female athlete triad are typically invested in their sports and would do almost anything to be the best athlete possible. Girls in particular sports have more of a risk than others. Sports with a weight class like wrestling, martial arts and rowing, and sports where being thin is more optimal for performing like gymnastics, diving, figure skating, cross country and ballet, have a higher risk. However, the truth is, being very thin, and losing those last few pounds, doesn’t typically improve performance at all.

If a female athlete is suspected to have the triad, a wide-ranging physical examination is needed for diagnosis. A doctor will likely ask questions about her period, diet, exercise habits and overall feelings about her body. From there, blood test will be ordered to check for vitamin deficiencies and to rule out any other reasons for a lack of period and weight loss. A doctor may also order a bone scan to check for osteoporosis, since the athlete will be at a higher risk for bone breaks.

Doctors will not work alone to help treat a girl with female athlete triad. Coaches, athletic trainers, parents, physical therapists, nutritionists and dietitians and mental health specialists all work together and play a role in the recovery of this athlete. They focus on both the physical and emotional issues that the girl is likely facing to help prevent long term issues.

References:

• https://kidshealth.org/en/teens/triad.html
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435916/
• https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/female-athlete-triad
• https://www.iofbonehealth.org/what-is-osteoporosis

By: Wyneisha Mason, MAT, ATC. ‘Neisha is an athletic trainer with RUSH Physical Therapy in Chicago, Illinois.

RUSH is part of the Select Medical Outpatient Division family of brands.

 

Posted on 9/7/2021

RUSH Physical Therapy’s Erin Short, P.T., DPT, recently joined Dr. Brian Cole, orthopedic sports medicine surgeon, and Steve Kashul, host of Chicago Bulls Basketball, on Sports Medicine Weekly to discuss how to avoid an injury while endurance training. Erin also discussed the role of physical therapy in helping patients before and after an injury. Check it out!

The podcast is now available to stream on Spotify, Apple Podcasts or wherever you enjoy your podcasts. More information can also be found at sportsmedicineweekly.com.