About Our Guest- Dr. Jay Greenstein – Assisting the body’s recovery from home office work stations
Dr. Jay Greenstein is the CEO of the Sport and Spine Companies – Sport and Spine Rehab, a multi-location, multi-disciplinary, evidenced-based practice in the Washington DC Metro region; Sport and Spine Athletics, a state-of-the-art health and fitness facility; the Sport and Spine Rehab Clinical Research Foundation, a 501-c3 dedicated to high quality, clinical research; and Kaizenovation® Consulting which coaches businesses on Six Sigma, human capital management and the Entrepreneurial Operating System®.
Dr. Greenstein was Chiropractor of the Year for both the Maryland and Virginia Chiropractic Association’s in 2010 and won the Smart CEO Volt Award for Technology Implementer for the small business category. He was recently selected to the state of Maryland’s Governor’s Office of Health Care Reform to serve on the Essential Health Benefits Committee. Dr. Greenstein sits on multiple community and business advisory boards in healthcare, banking and information technology.
Dr. Greenstein was also selected to be the Chef de Mission for the International Sports Chiropractic Association to run the Chiropractic Sports Center at the World Olympians Association Reunion Center at the 2008 Beijing Olympics.
Additionally with his clinical practice Dr. Greenstein has served as a recommended provider for the National Football League Players Association for the Washington Redskins, and since 1997, has been the Official Team Chiropractor for the Washington Redskins Cheerleaders.
Hyperice Hypervolt: Percussion therapy that helps relieve muscle soreness and stiffness, improves range of motion, promotes circulation and accelerates warmup and recovery..
Full Podcast Transcription
Dr. Jay Greenstein 00:00
If people are when people take responsibility for their own health and don’t rely on a pill or an injection, I think they’re going to find they’re going to be much healthier and much happier.
Diva Nagula 00:16
Hello everyone and welcome to another episode of From Doctor to Patient. Today, I have Dr. Greenstein with us. Dr. Greenstein is the CEO of Kaizo health companies a multilocation, chiropractic rehabilitation and wellness practice. He is also the founder of the Kaizo of Clinical Research Institute, a 501C3 which runs clinical studies to identify best practices. Dr. Greenstein is immediate past chairman for the clinical compass and the International Federation of Sports Chiropractic World Olympians Scholarship Program Chairman. Dr. Greenstein is also the CEO of Kaizenovate, a technology consulting firm that helps doctors of chiropractic grow their practices through technology. Dr. Greenstein is a sought out international speaker and consultant teaching clinical guidelines, leadership and business management. Dr. Greenstein sits on multiple advisory boards in healthcare and technology. Dr. Greenstein is also a very good and dear friend of mine. Jay, how are you today?
Dr. Jay Greenstein 01:34
Keep it what’s happening. Great to see you.
Diva Nagula 01:37
Thanks for being on this podcast. So how are you today? And how’s business going? During this COVID era, we’re in this mess of social restrictions and stay at home orders. How are you doing with with business in your arena?
Dr. Jay Greenstein 01:54
Yeah, I mean, it’s been a super interesting ride Diva, because this is, you know, I feel an opportunity for us to rethink, rebuild, restart our company. And we can find ways to innovate. And do you think differently, do you think it’s better coming out of this our in office visits are significantly down, we’re only seeing patients that are very acute. But the telehealth platform that we’re using and the services that we’re providing to that has exploded, we’re doing more telehealth consults every single day, every single week. And so that’s been a great way to connect with our patients and make sure that they’re getting some of the services. Obviously, we can’t adjust them and do all the good manual therapy through a telehealth console. But we can do other things like provide guidance for exercise, do evaluations, do revaluations identify sources of pain functional deficiencies, etc. So we’re able to really connect with our patients in ways that they’ve never experienced before. And I think that’s been a that’s been a huge positive.
Diva Nagula 02:52
That’s fantastic. And I know, it’s it’s, you guys are our essential business. Right. So your your doors are have remained open? Are you seeing a drop in volume of patients because of fear of exposure? And in that nature?
Dr. Jay Greenstein 03:07
100% Yeah, I mean, again, our in office visits are down. And the main thing is that people you know, are concerned about contracting COVID. And we understand that. So, you know, it’s really all about what’s best for the patient. And so if we can provide, you know, support and services for them, where they feel comfortable, you know, getting something like a telehealth consult at home, then we’re doing everything we can to keep our patients healthy, and, you know, at least maintain a level of function for them and a level of connection between us and them.
Diva Nagula 03:38
Do you find that when we truly get out of this COVID era? Do you find that your business is going to be changed?
Dr. Jay Greenstein 03:45
Yeah, I think so. I mean, we’re talking about ways that we can rethink, rebuild, restart our company all the time. And this is no different. We’re finding ways to innovate, we’re finding ways to be more efficient and more effective, identifying ways that we can drive clinical outcomes to an even greater degree. So I think there’s lots of opportunity coming out of this, this is a new experience. But as you know, my friend, this is all about how we, our mindset, this is about how we experience life. And if we are focused on the problem, it’s really hard to be creative and innovate. But if we’re focused on how we can be better coming out of it, then great things happen. And I’ve had amazing conversations and meetings, the people on my team, and we have great initiatives coming out of this that I think will help us do a better job, serving our patient population, and serving the community at large.
Diva Nagula 04:36
It’s really interesting, and I understand where you’re coming from. Because when you look at a perspective of a problem, and you’re faced with fear and anxiety, you’re very less likely to have a really good solution. But if you take it head on, and you have a team that does not have that fear, anxiety, you’re likely to solve that problem and come out way ahead. And I feel that you’ve demonstrated that with What you’re going through, and I feel that for me, I personally, this happened to me, you know, I actually run a IV hydration concierge business. And I immediately had some issues with fear and anxiety, because I was worried about the business actually surviving, and I didn’t know if it was going to. But I said to myself, let’s just find, you know, let’s just stop being anxious about the business. Let’s see if we can think of other solutions. So I came up with this pivot to start offering the COVID test and antibody testing. And I felt that that was a really good, unique way to still allow my nurses to go out into the field and do some work and get paid and still offer services to clients that really need it. So I agree with you. And I’m so I’m so really happy to hear about how your team is, is really looking forward and not really having to face fear and anxiety. And you guys are all coming together to come up with solutions.
Dr. Jay Greenstein 05:57
Yeah, I’m incredibly blessed. I mean, I’ve got just an unbelievable team, and they’re committed, they’ve all taken pay cuts, we have all taken pay cuts, their level of commitment has been like, unbelievable. And they don’t even talk about the pay or anything like that. They’re so focused, you know, on our mission and what we’re trying to accomplish, where we can, you know, truly, you know, inspire and empower a healthier, happier world, and what needs to change into your great term pivot. In order to do that, even better coming out of this. So there’s lots of work to do, I don’t know that I’ve ever worked harder, which is kind of crazy, because it’s like we’re seeing less patients, but I’m working even harder. I know that was possible. But it, it still is a great learning experience. You know, you and I were blessed because we got to see Ryan Holiday at the Qadri event. And one of the best books I’ve ever read and got me through some really hard times, is “The Obstacle is the Way”. And you know, the obstacle is about right now, that’s our path. So let’s embrace it. And let’s see what we can do with it to really make a huge difference in the world.
Diva Nagula 06:59
That’s, that’s incredible. And I’m really interested to see how the telehealth is going to be a big part of your practices. I think, in my mind, I think medicine in general, I think it’s going to take a huge shift. And I’ve also feel that we’re going to take a paradigm shift and how medicine is going to be practiced, not from a administrative instructional perspective, but also how we deliver health, I think we’re going to be going into a new era, where medicine is going to be looked at in a preventative sense, I think more and more people are going to be are going to empower themselves and not want to be a victim. And we’re seeing that over and over again, that people are really expressing their their anxieties and their fears about their health. And these are people who are actually being treated with medications, and they’re still having issues with their overall health. And what’s what’s what I’ve seen is that people are not having their root cause addressed. So they’re just being slapped with the medication, or was with some other treatment option that really doesn’t address the root problem. And I feel that the shift that we’re going to see is going to be where people want to be more interested in preventative care. And I can’t wait for that. Because as you know, I really espouse the ideas of functional medicine and integrative medicine. And, you know, I came from a traditional Western based medical practice in mindset. But I’ve shifted because my own personal health, do you you kind of see that that paradigm shift occurring?
empower themselves and not want to be a victim. And we’re seeing that over and over again, that people are really expressing their their anxieties and their fears about their health. And these are people who are actually being treated with medications, and they’re still having issues with their overall health. And what’s what’s what I’ve seen is that people are not having their root cause addressed. So they’re just being slapped with the medication, or was with some other treatment option that really doesn’t address the root problem. And I feel that the shift that we’re going to see is going to be where people want to be more interested in preventative care. And I can’t wait for that. Because as you know, I really espouse the ideas of functional medicine and integrative medicine. And, you know, I came from a traditional Western based medical practice in mindset. But I’ve shifted because my own personal health, do you you kind of see that that paradigm shift occurring?
Dr. Jay Greenstein 08:37
I’m typically an optimistic person, and I hope you are right. And you very well, maybe I have a little bit of skepticism that the system is going to move in that direction. I think there’s, I think there’s so much money at stake, that it’s hard for this system to really, you know, move this battleship. But what you’re doing and what you’ve done with your book, and what you’re doing with your podcast, is really getting the message out to the masses. So if we’re talking about, you know, people being empowered, and then taking responsibility for their own health, yes, I see that more and more do I see the system embracing that in a way that really can accelerate that progress? Unfortunately, no, but we can start somewhere, right, and what you’re doing, I think, and again, with your amazing book, and your podcast is really starting to educate people, a grassroots effort to create change at the at the end user so to speak, because if people are when people take responsibility for their own health and don’t rely on a pill or an injection, I think they’re gonna find they’re going to be much healthier, and much happier.
Diva Nagula 09:44
And I totally agree with you. And when we talk about statistics of our society, you know, we’re understanding why we see so much disease, specifically chronic disease like cancer. And the statistic is like, we You’re actually in a state where we see 70% of people across the country that are considered overweight and obese. And this is really awful. And on top of that, we’re seeing one out of every two people that are considering as pre diabetic. And in this case of COVID, you know, obesity is a risk factor for people that we see that are dying from from the virus. And we have to address this, because if we don’t address this, it’s going to really cause a lot of stress on our medical system. And we really need to address it at this point, so that we can save dollars in the future. And obesity, as you know, is a driver of inflammation. And by having so much inflammation in our bodies, it’s actually a driver to chronic disease. So we really need to find strategies, instead of just popping a pill and reducing blood pressure or popping a pill to treat diabetes, we really still need to tell these patients to “Well, let’s reduce the weight. Let’s talk about the diet, let’s talk about other issues, such as strategies to reduce stress, and such as mindfulness strategies, whether it’s meditating or my body exercises.” So I really feel that all that is, at least the conversations I’m hearing about people are talking about that more and more, which is a start, whether it’s going to change the system in general, probably not very soon, but at least a conversation is happening. So I’m really pleased about that.
Dr. Jay Greenstein 11:25
You know, it’s really, it’s really interesting, because a lot of a lot of what could be done within the system. You know, we talked about, yes, the masses need to understand this. And I think they’re getting a greater understanding, but the system needs to incentivize good behavior. And it doesn’t. I mean, if the healthcare system wanted to create good behavior, they would attach financial incentives to patients doing the right thing. And right now, that’s not happening. And certainly not to the degree that it needs to happen. In our world. You know, one insurance company said, if you go to the chiropractor, the first few visits are no copay. And they’re smart people. And I’ve seen their data like millions of data points over several years as it relates to, you know, portal of entry for spine care. And what they realize is you go see a chiropractor, and evidence based chiropractor is the first provider seen for non operative spine care. And the total cost of care is lowest across the board. So they can get folks moving that direction by by eliminating their copay for the first three visits, instead of going to a higher priced provider, that are going from multiple providers that really can’t fix their problem, then the insurance company wins and most importantly, that patient wins. And also with that the system was but there needs to be a lot more of that diet, exercise, functional nutrition that needs to be incentivized for us to actually make change at scale.
Diva Nagula 12:40
I agree. I mean, healthcare should be practiced that’s outcome driven, right, and not incentivized for ordering more diagnostic tests or having the patient come more frequently to your office to build them out each visit. So no, it should be outcome driven. And by that, I mean like, well, you’re getting paid more for having a person that’s achieving blood pressures that are normal without the use of antihypertensive medication. So that should be a point that is in the favor of the physician and a person should be dinged if they’re not following that outcome
Dr. Jay Greenstein 13:16 Agreed!
Diva Nagula 13:39
Also, I kinda want to talk about some things that we’re seeing during our stay at home restrictions. A lot of people are working from home. And like me, I’m often sitting at my desk for hours on the day, you know doing podcast or researching or doing conferences or whatever. And I find that if I’m doing this and I’m conscious of it, and I know that this is not the ideal thing, many other people are probably doing the same thing. And unfortunately, this causes problems in our body with with posture with stress in our bodies from sitting for prolonged periods of time, and as a chiropractor are you like seeing some of these issues pop up through your telehealth conferences?
Dr. Jay Greenstein 15:10
Yeah, we are. I mean, we’ve got lots of folks that are complaining about neck stiffness, upper back stiffness, low back pain, hip tightness, I mean, all the things that you would expect to see with people that are sitting for long periods of time, and there are ways that we can engage with patients or things that the audience can do that are listening right now, that are really simple ways to get moving again, you know, in our world, we, we say movement is medicine, right? diva, like movement is medicine, we got it, we got to get people moving. And so, you know, I think about a few things that are really, really important. The first thing is ergonomics, you know, very simple things that we can do with our computers and our laptops and our
sitting position that can help us actually improve our posture. So for instance, the middle of the computer screen being an eye level, you know, if you’ve got a laptop, and you don’t have like an external keyboard, or external mouse, and you need to raise up your laptop with a couple of books in order, you know, a laptop and an external mouse from Amazon for $9. And that’s going to help improve your posture and decrease the probability of you having pain and stiffness. Another thing is just, you know, you’re sitting posture, right, so you’re sitting posture needs to be shaped, you need to be thinking about almost like a string on the top of your head, pulling your head up, keeping your head erect, and your shoulders over your hips, and your hips and knees bent between 70 and 90 degrees. So that’s like the ergonomic situation, we also want people to get up out of their seats every 30 minutes, and just move around, we know how the body is designed. And if we, the longer we sent in, or the longer we remain in any position, quite frankly, the more stiffness there is specifically in the spine. So we need to be moving. So getting up every 30 minutes is really important. There’s great apps, excuse me, great apps for that, there’s you can set your timer on your phone, but just get up every 30 minutes. And then the last thing for the audience to know is like they’re a simple but effective exercises that people can do at home, that can help you know, stimulate their muscles and decrease stiffness and improve mobility. And so, you know, we have we have all kinds of content online, you can check us out at Kaiser health, but tons and tons of content that people can use and improve the mobility and decrease their stiffness and reduce the probability for having not just stiffness, but but pain and having future pain as well.
Diva Nagula 17:34
It’s that’s an awesome idea. concept. And I think that’s really important. And you’re able to convey this through telehealth. So it’s not like you need to see the person and evaluate them and touch them. These are all things that are going on because of the complaints of people that are expressing them are commonplace across the board. And these are natural things that we’re seeing from people who sit even at their workstation on a regular basis, even before COVID ever existed. So are there any other like, tools that you can advise? Like, what about those standup desks? Are you a big proponent of that?
Dr. Jay Greenstein 18:10
Great, you have a great point? Yeah, I’m a huge fan of standup desks, I think they’re great. Again, you don’t want to remain in any one posture for a long period of time. But it’s, it’s the movement, it’s the change in posture that can be extremely helpful. So yes, huge fan of standup desks. I actually really like as long as you maintain proper posture, I really like sitting on a Swiss ball, one of those, you know, rubber exercise balls, I think those can be really, really great, we can engage our core, we can improve our posture, as long as we’re consciously aware of it. But I love that there’s also a super cool product called QB, we’re actually running a clinical trial through our research foundation on this product, but it’s like, it’s like a little mini bike. It’s just pedals. And so you can actually sit at your desk, right, and you can pedale and you’re burning calories, and you’re awesome. And you’re staying mobile, you’re moving your lower extremities. So there’s many, many things that you can do like for me, over the weekend in between the things that I was doing for work, I was doing exercise sets, so I do a little bit of work, get up to a few sets of some exercises, and then go back to work. So I’m achieving multiple goals there, right? Not in one position for too long. The ergonomics are already set, because my computer screen is set up the right way. But I’m getting some exercise and doing things that I can where I can stimulate my joints, my muscles, my my heart rate, and really feel so much better at the end of the day because I’m doing those things, as opposed to just sitting in one position for eight or 10 hours.
Diva Nagula 19:40
Do you find that? I don’t know if you’ve measured but are you burning calories when you’re using that pedometer?
Dr. Jay Greenstein 19:47
So yeah, I mean, there are there have already been clinical studies that looked at calorie burn. And yes, not only do you burn calories during but you burn more calories afterwards, as well which is super cool. So we’re doing a lot larger scale study, and I can’t really talk about the results, but I think what we’re gonna find is this, it’s another really innovative thing that we can do for people that are sitting at their desk, like you said, even post COVID. It’s a really great tool.
Diva Nagula 20:14
Yeah. And another thing that I’ve also noticed for me is, well, one of the tools that I actually purchased from your office was a lumbar roll. And I’m actually using it right now, because it actually forces me to stay more erect, and my bodies stacked over my hips properly. So I’m engaging my core instead of slumping over and slouching and getting that rounded back. And so this is really great for me, because it builds up my core strength, and I’m able to sit in an appropriate posture while I’m on the computer for, you know, 30 minutes at a time, because I know, as you’re talking, I need to change my motions. And and so for what I am standing or sitting in my desk, I’m actually able to educate my body and perform a proper posture technique.
Dr. Jay Greenstein 21:00
Yeah, that’s fantastic. I mean, the ability for us to just engage muscles, even for a brief period of time, while sitting can really help us improve mobility, decrease stiffness and reduce the probability of pain.
Diva Nagula 21:11
Another thing that I’ve been doing while I’ve been sitting is that I recently been doing some research and had a great conversation on our previous podcast about red light therapy. And I’m a big fan of red light therapy, you know, it’s got so many benefits, you know, including like, combating the effects of our constant barrage of blue light exposure, and that’s from our screens. And it also, you know, it’s a great way of kind of like, introducing our bodies to proper light instead of artificial light, because a red light mimics the effects of the sunlight. And it I’ve been using it regular. And it seems to be since I’ve been using red light, while I’m working, that I actually fall asleep easier at night, because it stimulates melatonin production there today. And so in the evening rolls around, I’m appropriately stimulated to sleep instead of being wired awake, because on the exposure of all the blue lightens the screens and the artificial lights in my house. That’s one of the things that I’ve been used to as a hack to get me through this, because I’m sitting at my desk for so long.
Dr. Jay Greenstein 22:14
That’s phenomenal. I’m gonna have to check that out. I thought we were on a zoom, you know, last week together with some other fellow cadre members, and we saw you using it and it was really cool. So I got to check it out for sure.
Diva Nagula 22:25
Absolutely. That’s really I’m really impressed with all of the, with you, with you with your display in a research and is there anything else that you can discuss? without revealing what’s in the pipeline?
Dr. Jay Greenstein 22:41
Sure, yeah, we actually just got a multi-year multi-million dollar grant from NIH, and we’re studying the effect of vibration, and both heat and cold on acute and chronic pain. Our principal investigator is someone Her name is Amy Baxter. She’s a pediatric emergency room physician. And she’s phenomenal. She’s also an entrepreneur, she’s been on Shark Tank. When I saw her on Shark Tank, I actually just reached out to her through LinkedIn and said, Hey, we have a Research Institute, if you want to study your the effect of your product, let us know. And we can let you know we connected this for you know, a few communications back and forth. And two years later, she reached out to me and said, Hey, we’re ready to do a study. Do you want to be our clinical site? And we’re like, absolutely. Yeah. So that’s super exciting. And again, there’s, she’s, you know, very well versed in vibration, and the specific frequencies that block pain stimulus into the brain. And so she knows it really well. And it’s a very well designed product. So another innovative product that can really change pain management for the better, that we are both aligned and you know, decreasing injections, decreasing opioid prescriptions. And so that really is an exciting project. I just published a paper in pain medicine, which is the Journal of the American Academy of Pain Management. And that was an awesome study that was over 100,000 subjects. So it was a big data study. And it looked at the impact of chiropractic care on opioid prescriptions. And what we found is that, for patients who saw a chiropractor, the likelihood of them receiving an opiate prescription was one and a half times to two times less. And I mean, that’s a huge order of magnitude, right? So like when it comes to changing policy, and as you were talking about earlier, like changing what has to happen in healthcare today, you know, we really hope that will help move the needle to help patients understand how we can provide natural evidence based alternatives to their pain. And you know, I know you’re an expert in functional medicine, and it’s an area that I’m learning a bit more about with our mutual friend Cindy, but you know, you know, there’s so many other things that people can utilize on the nutrition side that can help you that can help people decrease pain and inflammation. Yes?
Diva Nagula 24:52
Correct. 100% there’s numerous tech modalities that we can we can discuss which I’ve discussed in many podcasts before. But yeah, exercise is one of them. And in proper nutrition, eating right balanced diets and staying away from processed foods, and even other modalities like mindfulness, and reducing the amount of stress that’s in your system, things like spiritual enlightenment, such as expressing gratitude, and establishing connection with other people, there is a lot of things that can reduce inflammation and promote well being. You’re talking about this vibrational study that, you know, that you were involved in, it kind of reminds me right now we’re stuck at home. And a lot of people use a licensed massage therapist to get massages, to really relieve tension to to loosen up muscles to elongate tissue. I’ve actually been using a product, which is, which actually kind of is it’s called hypervolt. So it’s like a jackhammer that provides this vibrational and sense to my body and actually breaks up. Are you a fan of that? And if if not, I mean, is there another product that we can use to simulate massage.
Dr. Jay Greenstein 26:08
So this was not set up at all, I want the audience know this. But yes, I’m a huge fan of hypervolt. And we are one of their one of our strategic partners. So we’re evaluating the effectiveness of hypervolt, as well, and it’s an awesome, awesome product. So yes, I’m a huge fan. And it’s a great great way to provide soft tissue treatment, and especially self administered soft tissue treatment that can be very clinically effective.
Diva Nagula 26:31
I had no idea i’m i’ve been using this product for almost a year and a half. And I use it regularly after workouts before workouts to get my tissue ready for working out, and then I use it afterwards to eliminate some of those tightness that I’ve accumulated for working out. So I’m sure there’s plenty of benefits from the the application of this. But while we’re sitting at home, you know, I mean, I’ve been missing going to my massage therapist two to three times, two times a month, or I’m sorry, two or three times like every other month. But what’s really cool is that now I’ve used this, I don’t, when we go back to regular style, post COVID, I won’t, I won’t need to go to the massage therapists that often because I’ve been taking care of my body using the tools in my house. And I’ve been also using a foam roller. So it’s like I’m actually saving money by using stuff that I have at home that are very inexpensive and actually provide just as much relief.
Dr. Jay Greenstein 27:32
So Dave, I’m so glad that you mentioned foam rolling because that is that is another really, really effective evidence based tool to improve range of motion for patients. And actually, there’s been several studies by a researcher named Dave Boehm, who’s up at Memorial University of Newfoundland, Canada. And, you know, he looked at the impact of foam rolling on flexibility. And what he found is that it’s way more effective than static stretching, I won’t bore the audience with the details and nerd out on it. But the bottom line is that it’s way more effective than static stretching. And actually, if you’re an athlete, it’s something that you really want to do prior to competition, because you can increase range of motion without decreasing muscular performance, whereas static stretching will decrease muscular performance. So I’m so glad you mentioned foam rolling because it’s a great tool. And it’s awesome for spine mobility to just rolling your spine out, especially your mid back your thoracic spine, with your arms overhead can increase thoracic extension, which can decrease stress on the cervical spine on your neck. So love, love, love foam rolling.
Diva Nagula 28:33
That’s awesome. I think we just given our listeners a bunch of tips to really help their bodies while they’re sitting at desk for prolonged periods. So, Jay, how can people find you on on the on the internet or through your office?
Dr. Jay Greenstein 28:50
Sure. So our Our website is www.Kaizo-health.com. And then you could just reach me if you have any questions. I’m more than happy to help if drjay@Kaizo-health.com. So, yeah, always willing and happy to help anybody that we can.
Diva Nagula 29:14
Jay thank you so much for being a guest on the show. And these are some great tips. I was so happy that we could be discussing today.
Dr. Jay Greenstein 29:22
Well, thanks for inviting me man. I enjoyed it. I always, always love hanging out with you,
Diva Nagula 29:26
Until next time, man, take care.
Dr. Jay Greenstein 29:29 Absolutely. Take it easy.