Should you need to stretch?

In an ideal world NO, You should not need to stretch – unless you participate in an activity that you hold no recent muscular conditioning for.

The most common reason people find themselves so reliant on stretching is due to holding muscular imbalances. These muscular imbalances cause certain muscle groups to carry the majority of the load (either physically activity or just daily movement), whilst other muscle groups are not able to support due to the biomechanical change caused from the imbalances.  

A common example is the runner who gets extremely tight calfs, quads and hip flexors. Weak gluteus maximus, hamstrings and adductor muscles allow the pelvis to anteriorly tilt forward which in turn shortens the hips flexors and quad muscles. As the person runs with all their weight forward of their midline, their calf muscles are having to work harder and harder to maintain the body in an upward position, hence resulting in excessively tight calfs, quads and hip flexors at the end of the run.

The runner diligently stretches, applies heat, foam rollers each night in an attempt to loosen off the tension so they can get out and run again the next day. Unfortunately this becomes a daily ritual purely because the muscular imbalances are never addressed.

A targeted exercise regime that focuses on eradicating tension to the quads, hip flexors, whilst strengthening the gluteus maximus, hamstrings and adductor muscles over time would eradicate the postural imbalances that lead to the continuous need to stretch.

A strong and balanced posture maintains good pelvic stability when you run, allowing the load and impact to distribute evenly through all the muscles of the body, most importantly to the posterior muscles that are designed to assist when running.

With the correct muscles carrying the load, the previously overloaded muscles all of a sudden feel so much less fatigued and tight after every run. Initially the correct muscles will be tight and fatigued as the are yet to be conditioned due to the extended period of not doing their part.

Once the runner builds conditioning with their perfectly symmetrical posture the desire or need to stretch becomes redundant.

The very same thing applies to the person who suffers from lower back pain. They go home each night and stretch, apply heat and foam roll just to loosen up their tight back.

No different to the runner, if the back suffer addresses the underlying cause and strengthens their postural muscular imbalances, they will eradicate their back pain and eliminate the need to stretch out their back each night after work.

In summary, if you maintain perfect postural symmetry, then all of your muscles are working at their optimal length.  The correct major muscles of the hips and trunk are carrying the load and impact of all your human movement.  To eradicate pain and the need for unnecessary hours spent stretching each week focus on addressing the underlying imbalances present in your body.

What if there was a unique way to squat that could fix your back?

There are many different ways to squat, let’s look at the most common:

  1. Bodybuilding squat: shallow squats with knees forward of the midline. Why? Because this particular technique loads up the quadriceps muscles. Perfect for the bodybuilder who wants big, conditioned quadriceps muscles, especially if he or she has an upcoming competition.
  2. Powerlifting squats: deep squats, knees slightly forward of the midline. Why?  Powerlifters or olympic lifters have one chief aim, to lift as much as they possibly can either up and over their head (clean and jerk), up onto their chest (clean), or up off the ground with straight hanging arms (deadlift). Powerlifters squat in a sports specific functional manner that incorporates all the leg, hip, trunk and arm muscles to assist them in their chief training aim.  
  3. Elite Sprinters Squats: Deep squats, knees not forward of midline, torso more horizontal than a traditional squat. Why? Sprinters are all about power to weight ratios. The major posterior muscles generate all the power that propels sprinters across the track. Ideally a sprinter wants massive gluteal and hamstrings muscles, and extremely lean anterior and upper body muscles.  

If you have been to a gym, and have been shown how to squat, you most likely were shown how to squat like a bodybuilder. Why? Who were gyms created for, who became the first gym instructors??.. You guessed it, Bodybuilders!! There is nothing wrong with this, nor the history of how gyms came about, however what it means is that you need to be 100% clear on what your core objective is with your training, notably your weight training and how you squat.

If you intend on being a bodybuilder or you are a young male teenager who like most his own age has a strong innate desire to pile on a mass of lean muscles, then we recommend following the crowd.

If you do not, then you need a specific weight training regime tailored to your personal needs. Squats are the most functional and rapid way to get results, however they are tough and hard to master. If you just go to your gym and ask your local instructor, then you most likely are going to be doing squats in a way more suited to bodybuilding that what you really want to achieve.

So if you want to be a:

  • Bodybuilder, squat like a bodybuilder
  • If you want to be a powerlifter, squat like a powerlifter

However if you want to:  

  • Squat to fix your back
  • Squat to improve your posture
  • Squat to improve you top end speed, vertical leap and power for sport
  • Squat to have a tight/ toned inner thighs, rock hard abs and buttocks (a.k.a look like a sprinter. 

Then it is pretty clear that you should buck the trend of the crowd and squat like a sprinter.

Be warned:

– You are in for some rapid and phenomenal results that will blow you and your friends and family away.

– Expect lots of funny looks from other gym goers as they wonder why you are squatting with a funny unorthodox technique.

– Expect the people who initially give you funny looks to start copying you when quickly notice your amazing improvements:).

Get to the gym, fix your back, improve your posture and enjoy your rock hard inner thighs, abs and buttocks.

How can sprint training fix my poor posture?

Picture the posture and physique of a sprinter vs a long distance marathon runner.

In order to propel yourself across the running track, you need to generate power from your major postural muscles. The posterior muscles of the body, and the deep trunk muscles are what make you run fast. So the very act of sprinting, or participating in a training regime designed to make you faster by regularly spriting is one of the most functional and effective ways to improve your posture.

Good Posture is governed by a solid and strong base. Think of the pelvis as your centre of gravity, and what should be your solid base. If the pelvis in not in its correct and neutral position due to muscular imbalances, then your lower limb biomechanics will be affected, the natural curves of the spine compromised along with your upper body strength and balance.

The vast majority of people who live in the western world, stuck at desks or carrying out tasks that keep them in a fixed position working forward of their midline for hours on end each and every day. This lifestyle causes imbalances, the anterior muscles of the body become tight and restricted (shortened), whilst the posterior muscles of the body become underused and weakened (lengthened). This creates what is called an anterior pelvic tilt, with the shortened anterior muscles pulling the front of the pelvis downwards, with the posterior muscles providing no stability or support due to being weak and lengthened.      

In order to obtain a good posture, you need to start with the base (the pelvis). The pelvis needs to be in a strong and stable position in order for the lower limbs, the spine and the upper body to function optimally.

Sprint training rectifies and offsets the effects of our modern sedentary lifestyles.

The very act of attempting to sprint faster and faster each session:  

  • Strengthens the muscle that support pelvic stability
  • Strengthens the deep muscles of the trunk (core)
  • Strengthens the posterior muscles of the body; hamstrings, gluteus maximus, adductors

The areas you will notice improvement and change:

  • Your gluteus muscles will become strong and toned
  • Your inner thigh muscles will become strong and toned
  • You will have stronger and more toned abdominal muscles  
  • You will actually become leaner in the quadriceps muscles (providing you are not overtraining at other activities in the gym)
  • You will actually become leaner in the upper body muscles (providing you are not overtraining at other activities in the gym)

Other health benefits gained from sprint training:

  • Increased lean muscle mass
  • Increased basal metabolic rate (meaning you will burn more fat during rest)
  • Increased blood circulation
  • Improved digestion/ elimination of waste.

In conclusion, sprinters look like pictures of health. You don’t need to hit the gym four hours a day to reap the benefits of a sprinter’s health and physique. You just need to sprint, 1-2 x p/w week is more than enough.

For more information on how to fix your posture and your back pain through sprint training, please read relevant articles on our site.

Lower Back Pain

How do tight hip flexors play a role in back pain?

The link between tight or shortened hip flexor muscles and back pain is often misunderstood or completely overlooked.

It is important to understand that the source of back pain is almost always coming from the structures of the lower back. However the underlying cause, especially in chronic back pain sufferers is almost always due to other areas of the body being tight and being weak which compromises the lower back and the way that chronic sufferer uses their back.

Let’s take a closer look at some of the sources of back pain:

  • Tightened, restricted lower back muscles
  • Restricted joints such as facet joints and sacroiliac joints.
  • Intervertebral disc derived Inflammation
  • Solidified connective tissue

As you will note, all of the sources listed above are structures in the lower back region which makes complete sense as there is a direct link between the source of the pain and the area where the patient feels the pain. As mentioned above, the source of back pain and the underlying cause are two very different things, and this is where it becomes complicated for people to understand.  

Now let’s take a closer look at the underlying cause of chronic back pain and how the hip flexors play a major role in it:

  • Weak posterior muscles; gluteus maximus, hamstrings, adductors
  • Tight anterior muscles; quadriceps, hips flexor, iliopsoas

Weakened posterior muscles that are supposed to support us in an upright position, cause us to compensate by placing more of our body weight forward of our midline. What this does is overload our anterior muscles, causing them to become more dominate, tight and restricted.

The hips flexors are at the front of the hip, crossing over the hip joint, originating on the spine and inserting onto the femur (upper leg bone). With weakened posterior muscles, the hip flexor muscles take most of the person’s body weight when standing, walking, let alone during physical activity. As a result the hip flexor muscle group becomes shorter which combined with having weakened (lengthened) posterior muscles creates a downward force on the entire pelvis.

This combination between weak posterior muscles and tight anterior muscles creates what is referred to as an anterior pelvic tilt. With the pelvis tilting down or forward, the curves of the spine must compensate in order to maintain a level eyeline.

This creates an excessive lordotic lumbar curve which in turn compromises the structures of the lower back; lower back muscles, joints, discs, connective tissues.

Whilst it is important to note that the source of pain comes from the lower back, it is imperative to understand that the true underlying cause of lower back pain comes from postural imbalances due to lack of muscular symmetry.  The hip flexor muscles are one of the chief culprits that pull the pelvis in a position that compromises the lower back structures, in turn causing tension and restriction that results in pain.

Why avoiding leg exercises at the gym will lead you to lower back complaints?

This should be so self explanatory, that it should need not to be covered. However for the majority of gym going males, the drive for a strong upper body physique almost equals the lack of desire to tough it out on the lower body exercises.

To allay concerns that this article has a sexist tone in that it is directed to males – we only need to remind you of the masculine looking male walking on the beach in tracksuit pants. Great upper body physique out on show, with the tracksuit pants hiding the chicken legs.  Women tend to hold more focus on how their legs look and are a lot more vigilant in training both their upper and lower body.

Lets face it squats are tough, as are dead lifts. They are full compound exercises that work the major muscle groups of the body. Body builders are obsessed with them, as they are well aware of the knock on benefits to all areas of the body that come with mastering these lower body exercises. The ametuer gym goer is typically short of time, resulting in the lower part of the body being neglected.

Neglecting the lower body, whilst increasing both muscle size and strength does not only create an ascetical imbalance, it creates a major postural imbalance that often leads to lower back complaints.  If you think of the major leg and hip muscles as the base or foundation that supports the upper body, then it only makes sense that if the upper body is becoming heavier and producing more powerful movements, then the base/ foundation needs to be stronger.

The biomechanical side effects of having a stronger and heavier upper body, with a weakened under trained mid region and lower body:

  • Weakened major postural such as gluteus maximus, hamstrings and adductors fail to support the weight of the upper body.
  • The body compensates with an anterior pelvic tilt due to instability
  • The anterior pelvic tilt results in the majority of the person’s body weight placed on the muscles forward on the midline.
  • The anterior muscles such as the hip flexors and deep internal rotators of the hips become overloaded and shortened.
  • Weak posterior muscles, tight anterior muscles and an anterior pelvic tilt results causes the lumbar spine to excessively curve (hyperlordotic).
  • A hyperlordotic curve compromises the joints, muscles, intervertebral discs and the fascia of the lower back.
  • Postural weaknesses and imbalances result in the lower back not being supported one the person is in an upright position and moving.
  • The lack of support for the back and the compromised structures due to hyperlordosis eventually result in an injury that can be long lasting.  

So the message it quite clear, if you want to avoid back pain, train your body. Sure lower body exercises can be tough, and can be time consuming when lifting heavy. However you will be thankful in the long run. We have added some tips below, to try ensure you get the best results with the minimum amount of time and effort spent 🙂

Tips to incorporating lower body exercises into your regime:

  1. Leverage your time, forget isolation exercises, functional compound movements such as  squats and deadlifts are all you need to do.
  2. Do the hard yards early, then maintain. Build up to at least your own body weight.
  3. Work in the power range: maximal output, max reps of 5, 3-4 sets. And here’s the big pay off – providing you’re training with intensity, 1 session per week of power training is more than adequate.  
  4. Maintain with a weight you are comfortable with (at or above your own body weight). This will avoid longer rest periods between sets, and obviously save you busting your guts each and every leg session.

Exercises where you consciously activate your glute muscles is a futile exercise!

Exercises where you consciously activate your glute muscles is a futile exercise!

The major glute muscles, the gluteus maximus’ primary role is to support us in an upright position when standing and when walking.

If the pelvis is maintained in a neutral position then the gluteus maximus muscle will automatically function and naturally activate under load.

However if the pelvis is not in a neutral position, instead in an anteriorly tilted position, then the gluteus maximus muscle is no longer in a biomechanical position to carry out its natural role.

For the person with an anterior pelvic tilt, the majority of their body weight is distributed forward of their midline. The anterior muscles of the body, the hip flexor group predominantly compensate and take on much of the load.

This compensatory position becomes perpetuating – the anterior muscles become more dominate, overloaded, short and contracted which creates a further downward pressure on an already anteriorly tilted pelvis. This further negates the ability for the posterior muscles, gluteus maximus, hamstrings and adductor muscles from carrying out their role causing them to quickly atrophy (reduce in size and strength) due to the lack of stimulus.

With tight, shortened anterior muscles creating a downward force on the pelvis and weakened,, elongated posterior muscles not able to support the pelvis in a neutral position the compensatory patterns is set in.

No amount of consciously activating, squeezing, trying to feel your glute muscles will override gravity. If all of your body weight is forward of your midline, then how on earth will squeezing your glute muscles or focusing on activating them correct this? Yet this is the approach taken by many healthcare practitioners and fitness trainers.

It is a futile approach that holds absolutely no lasting effect. As soon as you complete the activation exercises then stand up – guess what, all your weight is back on your anterior muscles and the very muscles you were activating are still not in a position to carry out its correct function. You could literally do this all day for a hundred years and it would still not have any relevant or notable impact on its so called chief aim – to get the glutes to activate during everyday activity.

A more practical approach is to focus on exercises or movement patterns that elongate (stretch) the tight, dominate anterior muscles whilst simultaneously strengthening the weak posterior muscles (the gluteus maximus being one of those).   

The short term benefit will be increased strength and growth to the gluteus maximus, however more importantly over time the compensatory position will be eradicated. Providing the right amount of resistance is added over time with sound technique, the pelvis will return to its neutral position. With a neutral pelvis the gluteus maximus muscle will be back in the perfect position to work all day every day to support the weight of your body when upright.

What should I do if I run and I am getting back pain?

Running is one of the most effective ways to improve cardiovascular fitness and burn calories. The issue for most people is how challenging running is on the body, especially if you are predisposed to back pain.

In this article we will break it down into different sections to best guide people concerned about their back, yet are keen to achieve or maintain the great benefits running provides. Please read through the different segments and establish which scenario best describes your situation.

  1. New to running, starting to get back pain

Running requires both core (trunk) and gluteal (gluteus maximus) strength and conditioning. For many people their reason for getting into running in the first place is due to carrying excessive weight and or being unfit. It is fair to say that the majority of people with the goal to lose weight and get fit have a very weak core and very weak gluteal muscles.  This leads to problems, and most often the back becomes one of these problems for new runners. If the running technique is not supported by the trunk and gluteal muscles, the back becomes overloaded, fatigued and tight which in turn causes pain either during or after running. This is not a major concern in the sense that any damage is being done, however it is significant enough to end the new found goal of running to lose weight and get fit.

Below are some tips to guide you in the right direction.

  • Try to reduce the distance you are running. Most people feel fine for the first 5 mins or 1-2 km of running, with back pain commencing post this. Start off with shorter runs, and work on getting faster over that speed before you increase the distance.
  • Commence exercises such as squats and deadlifts to strengthen the muscles that support the lower back when running
  • Commence sprint training to strengthen the muscles that support good posture and running (refer relevant articles on sprinting on this site)  
  1. Haven’t ran for a prolonged period, starting to get back into running and experiencing back pain

Most likely the muscles that were once strong and conditioned when you were constantly running have atrophied during your hiatus. You will still be able to run quicker and longer than a new time runner, which places even more load on your back, due to the lack of support from your once conditioned trunk and gluteal muscles. No different to new time runners, you need to re-condition yourself first and gently build up to what you were once able to achieve.

Below are some tips to guide you in the right direction.

  • Try to reduce the distance you are running. Most people feel fine for the first 5 mins or 1-2 km of running, with back pain commencing post this. Start of with shorter runs, and work on getting faster over that speed before you increase the distance.
  • Commence exercises such as squats and deadlifts to strengthen the muscles that support the lower back when running
  • Commence sprint training to strengthen the muscles that support good posture and running (refer articles on this site)  
  1. You are a seasoned runner and have started experiencing back pain.

Of the 3 scenarios this is the one we tend to take more seriously. For new runners your back is not supported due to prolonged periods of inactivity that leads to postural weaknesses.

If you are and seasoned runner and you have only just experienced back pain we suggest that you seek quality myotherapy (massage therapy) to work deeply through the muscles of the hips and lower back. For some runners, tightness can occur in the muscles of the lower back and hips either over a period of time or from slight overtraining. For many seasoned runners experiencing back pain, a series of treatments resolves the issues and myotherapy becomes a maintenance strategy against recurrence.   

For the seasoned runners experiencing back pain who are not getting relief from treatment then another approach needs to be taken.

Over time a runner’s posture can change, weaknesses can set into the posterior muscles (gluteus maximus, hamstring, adductors), which in turn places a greater load (especially when running) onto the anterior muscles (hip flexors). This muscular imbalance causes the pelvis to anteriorly tilt, which creates an excessive curve in the lumbar spine (hyperlordosis). The excessive curve shortens and compresses the structures of the lower back. The major gluteal muscles and posterior muscles not only support the lower back when running, the act as a cushioning or a shock absorption for the spine and lower back structures. So with the lower back structures already compromised and the cushioning removed with each step of running pain sets in very quick for the runner.

Below are some tips to guide you in the right direction.

  • As best as possible rest/ or reduce running load to allow back to settle down
  • Seek quality treatment to free up the structures of the lower back
  • Commence rehabilitative program to elongate the anterior muscles and the strengthen the posterior muscles
  • As you commence running, shorten the distance and work on speed/ not endurance. The faster you run, the more the posterior muscles need to work, so this will complement your rehabilitation progress.
  • Commence sprint training to strengthen the muscles that support good posture and running (refer articles on this site)  

You don’t need to lose weight in order to fix your back pain!

One of the most common things people are told with lower back pain who also happen to carry some excess kilos is that in order to fix their back, they need to lose weight.

Let’s look at how absurd this common statement is:

  • Many people with chronic back pain can not exercise, and as a result they put on excessive weight. They had the exact same level of back pain at a healthy weight, as they do when they seek advice from their practitioner.
  • Advising the cause of their back pain is from carrying excess weight.. Wouldn’t that imply that all overweight people have back pain??
  • And what about all the skinny people out there who suffer from back pain? Is losing more weight going to help them too?
  • Many people told to lose weight by their practitioner, adhere to their every word and regain a healthy physique, only to still have their debilitating back pain.. Now what??
  • Most people are as desperate to lose their excessive weight as they are to fix their back pain, however they cannot exercise due to their pain which makes the incorrect advice even more frustrating to the back pain sufferer.

How about we change the paradigm:

  • Fix the back pain and strengthen the body so it never returns.
  • Then focus on losing the excess weight when been able to do quality exercise becomes an option to the now pain free, former back pain sufferer.

Being overweight has nothing to do with lower back pain. I will admit there are many other health concerns that come with carrying excessive adipose tissue, however the point we are making is that you need to address the cause of chronic back pain and often times being overweight is just a symptom.. Yes a symptom, where people put on extra kilos as a result of being inactive and comfort eating due to the pain and stress in suffering from long term chronic back pain.  

Regardless of your age, weight, sex or race, chronic back pain is brought on by muscular imbalances that lead to postural asymmetry. Address the muscular imbalances made up of muscle groups that are over dominate, tight and shortened (anterior muscles groups) and weak, lengthened (posterior muscle groups) then the lower back pain will be eradicated.   

With a new found symmetrical posture, not only will the patient have a pain free back, their body and mind will be well prepared to commence the task of losing the excessive weight often accumulated over years of chronic back pain.

Prescription of antidepressant drugs for chronic back pain should not be considered lightly.

For the vast majority of back pain sufferers prescribed with antidepressant medication, depression (or more accurately their depressed state or feeling) is purely a byproduct or symptom of their back pain.  

None of these people had depression when they were pain free. More importantly if their debilitating back pain was eradicated they would no longer have the depressed feelings associated with chronic back pain.  

Antidepressant drugs play an integral role for people suffering from mental health issues.

To clarify, this article by no means is discrediting the importance and effectiveness these drugs have in helping people.

However, when they are prescribed to people who only have feelings of depression for one reason and one reason only – chronic back pain, then we strongly disagree with this medical intervening approach.  

For most people what does chronic back pain represent? The dull ache or even severe pain drains people, but rarely is this what causes people to feel depressed.

It is what chronic back pain takes away from them:

  • The husband/ father whose highest value is his work and providing for his family. The fear of not being able to continue work due to chronic back pain creates natural feelings of stress, anxiety and depression.
  • The wife/ mother that cannot bend over to pick up the children or stand at a bench to prepare meals for fear of her back going into a severe spasm.
  • The young adult who cannot socialise with friends due to long periods of standing and alcohol consumption flaring up the inflamed discs of the lower back.
  • The student who can no longer study due to the agony of being seated for long periods of time with chronic back pain

Whilst the reasons people feel depressed are different, they all link back to what is most important to that individual (ie their highest value). If you take away what is most important to people, the natural byproduct is loss, stress and a depressed state.  

The sole focus must be on addressing the chronic back pain and eradicating it.  Mind altering drugs are not the answer to chronic back pain, they are just a short term band-aid solution to the effect on the mind that chronic back back creates. The problem with these drugs is that the side effects often interfere with the process of correctly rehabilitating ones back pain. The side effects of antidepressant drugs prescribed to people who do not have mental health issues, who have natural depressed feelings due to the loss (most often temporary) of what they love most in life can have a lasting negative effect.

Despite what you’ve been told, a large percentage of back pain can be helped!

97% of chronic back pain is curable.

For the vast majority of people suffering from chronic debilitating back pain, they go from doctor to doctor, practitioner to practitioner in a desperate attempt to find a lasting solution to their pain.

As each appointment hands out more conflicting information on ‘the why I have back pain’ and the lack of lasting relief offered, confusion sets in. Everybody knows of a ‘guru’, a practitioner who you as a back pain sufferer just has to go and visit. Each and every time, more of the same. More temporary relief only for the pain to return, and worse still more confusion and a feeling hopelessness.

The concerning part is that this is the norm, not the exception. Patients spend thousands, often tens of thousands of dollars seeing specialists, getting scans, trying new therapies in a desperate attempt to rid their back pain and resume a normal healthy lifestyle once again.

After months, more often years and decades without a solution to their pain, the reality or more accurately the reality of the back specialists kicks in. ‘You are going to have to live with the pain’, ‘we recommend you go to a pain management clinic’, ‘here is this medication to ease the pain’.   

The healthcare industry fails chronic back pain sufferers by focusing and treating purely on the symptoms of back pain and not the underlying cause. The vast majority of chronic back pain is caused by the muscles, tendons and fascia of the lower back which is confusing given that all the specialists, doctors, practitioners refer to wear and tear of the spine and intervertebral discs.

X-rays and MRI scans show signs of wear and tear or degeneration of the spine and it’s discs, however up to 40% of adults have herniated discs, with the vast majority of them not experiencing pain. Up to 70% of adults have disc degeneration, once again with the majority not experiencing pain.

Wear and tear of the spine and or disc degeneration is rarely ever the true cause of chronic lower back pain, it is just a natural process of ageing. If the muscles that support the structures of the lower back are strong, balanced and working together then the person will not have back pain, regardless of the what the scans show and how the specialist has interrupted them.  

Show us someone with a perfectly symmetrical musculoskeletal system who has chronic lower back pain? In over 15 years, treating over ten thousand patients with chronic lower back pain, we have not seen one patient present to our clinic with sound posture, with muscle symmetry adequate to support their lower back.

Forget the symptoms of lower back pain and focus on the cause. Help the back by i) strengthening the atrophied muscles integral to its support. ii) Free up the restricted muscles that are placing it under load. iii) Restore functional, fluent movement where all the muscles of the body are working synergistically as they are designed to.

So regardless of what any specialist has told you – You can fix your chronic back pain for good,  regardless of whether you have suffered for months, years or decades if you focus on the true cause of your pain, not distracted by the symptoms.