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Atlantoaxial Osteoarthritis
Top Contributors - Marie Avau, Debby Decock, Gloria Carbonell Villanueva, Evan Thomas and Kim Jackson Laure-Anne Callewaert en Farrie Bakalli
- 1 Definition/Description
- 2 Clinically Relevant Anatomy
- 3 Epidemiology /Etiology
- 4 Characteristics/Clinical Presentation
- 5 Differential Diagnosis
- 6 Diagnostic Procedures
- 7 Outcome Measures
- 8 Examination
- 9 Medical Management
- 10 Physical Therapy Management
- 11 Manual Therapy - Manipulations and Mobilizations
- 12 Low-Power Laser Therapy
- 13 Pulsed Electromagnetic Fields.
- 14 Infra-Red Stimulation of Local Trigger Points
- 15 Massage
- 16 Short Term Results of Physiotherapy
- 17 Key Research
- 18 Resource
- 19 Clinical Bottom Line
- 20 References
Atlantoaxial Osteoarthritis is a metabolically active, dynamic process that involves all joint tissues such as cartilage, synovium/capsule, ligaments and muscles. It refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life[1][2].(Level of evidence 5, Level of evidence 1B)
Atlantoaxial osteoarthritis can be divided into:
- idiopathic
- degenerative
- posttraumatic osteoarthritis
Atlantoaxial Osteoarthritis in elderly is most often a result of a degenerative disorder and in younger patients it is because of a trauma.[3][4] (Level of evidence 3A, Level of evidence 4) This joint, similar to other joints in the body is prone to arthritis, but degenerative arthritis of this joint is an uncommon pathology [5][6] (Level of evidence 2B, Level of evidence 4)
Clinically Relevant Anatomy
See Atlanto-axial joint and Cervical Vertebrae
Epidemiology /Etiology
Idiopathic osteoarthritis occurs in the elderly, whereas posttraumatic osteoarthritis occurs more often in the younger population. It has a prevalence between 4 and 8%[7][8] . Only a minority of patients become symptomatic. Most (symptomatic) patients are female (74%) and present a unilateral osteoarthritis, which is typically triggered by rotation and can ascend to the occiput and towards the front.[8][9]
Liu et al. found that the rate of osteoarthritis was 16% in the age group 18-25 years, 23% in the age group 25-30 years, 33% in the age group 30-40 years, 54% in the age group 40-50 years, 70% in the age group 50-60 years, 87% in the age group 60-70 years, and 93% in the age group >70 years. [10] In addition, the severity of the osteoarthritis increases with age.[10][11]
The presence or severity of ostearthritis of the atlanto-odentoid joint is not gender dependent.[10][12] (Level of evidence 2B, Level of evidence 2B)
The incidence of atlanto-odontoid degeneration is very high in patients who have had an odontoid fracture but it's remarkable that the lateral atlantoaxial joints are relatively spared.[12]Head loading is also a known cause of degeneration affecting the occipito-cervical region. [11] (Level of evidence 2B)
Characteristics/Clinical Presentation
The most clinical symptom of atlantoaxial osteoarthritis is unilateral occipitocervical pain aggravated by head rotation. The pain ascends unilaterally to the occiput, the parietal skull and in some cases even to the eye. Degenerative changes of atlantodens and atlanto-axial facet joints can contribute to pain, and motion and sensory limitations that increase exponentially with age. [13] [11]:
Clinical Presentation
- A unilateral neck pain occurs with the slightest head rotation. The pain ascends unilaterally to the occiput, the parietal skull and sometimes even to the eye. [7][8]
- Visual problems often leading to an ophthalmologic work up. [7][8]
- A painful audible crepitation with head rotation. [7][8]
- Spasms in the surrounding muscles and by limiting the range of motion (ROM) of the neck, especially in the plane of axial rotation of C1-C2. [14][7]
The severity of the symptoms does not seem to correspond with the severity of the atlanto-axial osteoarthritis. In a study of Badve et al. there is no statistically significant association between presence of radiologic changes in male porters and their symptoms.[11] According to Betsch MW et al. degeneration is associated with dens fractures, therefore cervical spine radiographs should be assessed for changes of atlantodens and atlanto-axial facet joints. [13]
Differential Diagnosis
Common: [15]
- Cervical strain
- Acute whiplash
- Rheumatoid arthritis
- Cervical facet syndrome
- Spasmodic torticollis
- Cervical fracture (Jefferson fracture, Odontoid fractures, Hangman's fracture)
- Cervical dislocation
- Cervical radiculopathy
- Cervical Myelopathy
- Cancer: Metastatic or primary
- Meningitis
- Vertebral osteotomy
- Epidural abscess
Because of the rare prevalence, degenerative fibrosis of atlantoaxial osteoarthritis can be confused with other pathologic entities, such as rheumatoid fibrosis, tumors and migrated disc herniation.[7]
It is also important that atlantoaxial joint osteoarthritis should be considered in the differential diagnosis in elderly patients examined for neck pain with or without progressive quadriparesis.
The identification of a periodontoid ligamentous degenerative mass suggests the presence of instability of the atlantoaxial joint.[9]
Diagnostic Procedures
The clinical evaluation is important for making a diagnosis. It consists of : [14][14][7]
• The medical history which includes: the type, the start, the location and duration of symptoms, joint function, medical condition of the patient, medication, other treatments, family history, things that cause or aggravate pain, red flags… [7]They are all important considerations in assessing cervical spine patients.[14]
• Physical examination, which includes: pain on range of motion tests, limitation of range of motion, evaluation of spinal joints (pseudoclaudication caused by spinal stenosis), nerve tests (motor weakness caused by nerve root impingement), lower extremity sensory loss, reflexes, active examination, ... Gait troubles, loss of function, coordination issues and symptoms consistent with relative progression, are all important factors to consider. [14]
A diagnosis can easily be made based on the history of the patient and the physical examination. Osteoarthritis is a clinical diagnosis. Questionnaires and visual analog scores can be helpful for quantifying debility and how much the pathology is affecting daily life activities.
Radiology can be helpful in confirming the diagnosis and ruling out other pathologies (see 'differential Diagnosis'). It can identify degeneration of joints, the presence of trauma, and bone related disorders. However, radiologic findings of osteaoarthritis do not correlate to the severity of the osteoarthritis and associated symptomes. The findings are nonspecific and imaging is limited because of difficulties in direct visual assessment of the related joint, manifestations of non specific symptoms and unfamiliarity with the pathology of the care provider. [10](level of evidence 4) Conventional computed tomography , multidetector computed tomography and other advanced imaging techniques (such as MRI or CT) can be used to examine the presence of atlantoaxial osteoarthritis unless the diagnosis is uncertain.[11][10] [14]
Blood tests and laboratory testing can be done to rule out other conditions such as arthritis, a fracture, spinal tumor, infections, tumors, ... [14][7]
A CT scan may also be helpful in determining the extent of osteophyte formation and for planning surgery. Verification of the origin of pain by intra-articular blocks is recommended.[8]
Outcome Measures
- Neck Disability Index
- Neck Bournemouth Questionnaire
- Neck Pain and Disability Scale
- Numeric Pain Rating Scale
- Pain Catastrophizing Scale
- Visual Analogue Scale
The examination consists of a clinical and/or radiological diagnosis. The radiological diagnosis is primarily made on a standard atlas view, showing you the narrowing of the C1-C2 joint space. A bone scan showing increased uptake can also help to establish the diagnosis but is not mandatory. A CT scan can be performed to rule out a tumor or to assess the anatomical details of C1/C2 prior to screw fixation. Both clinical and radiological diagnoses have to be confirmed by intra-articular C1-C2 blocks.[8][8] (level of evidence 2B)
(See Category:Cervical Examination and Cervical examination for more information)
Medical Management
One of the medical interventions used for atlantoaxial osteoarthritis is the injection of glucocorticoid. These injections are placed into the lateral atlantoaxial joints and have shown to be a valid treatment alternative in patients who fail to respond to conventional noninvasive therapy.[16](Level of evidence 2B)
Furthermore the drug gabapentin may be useful in the symptomatic treatment of atlantoaxial osteoarthritis because of occipital neuralgia (greater or lesser). In the absence of subluxation or causes that require surgery, gabapentin may be a second-choice oral therapy before invasive procedures. Also high-dose nonsteroidal anti-inflammatory drugs, muscle relaxants, tricyclic antidepressants, prednisone, and tapered or short-term narcotic agents have been suggested as oral medications. [9](Level of evidence 2A)
If all conservative treatment fails, the third and last option is surgery, more specifically spinal fusion of C1-2. In this procedure the vertebral body of C1 and C2 is fused with screws to regain full stability. [8](level of evidence 4). A meta-analysis about posterior C1-C2 fusion indicates that posterior C1-2 fusion is a safe and effective solution for patients with lateral AAOA combined with neck pain.
If conservative therapies fail to provide sufficient pain relief, modern fusion options offer low risk of morbidity and a high rate of arthrodesis.[10](Level of evidence 2A). A retrospective study by Grob et al showed positive results on several outcomes after C1-2 fusion. All the patients showed solid fusion, 89% was pain free or showed a significant decrease in pain and only 11% had minor complications. This resulted in 85% of the patients who would perform the surgery again. [8] (level of evidence 3B). The polyaxial screw–rod system is one of the possibilities which has been proven to be effective. The authors of a series of cases concluded that the possibility of a temporary fixation without damage to the atlantoaxial joints and of reduction after the screws and rods had been inserted is quite unique. [16] (level of evidence 4)
Physical Therapy Management
The physical therapy for atlantoaxial osteoarthritis includes a combination of different treatments such as neck support exercise programs, manipulation in combination with joint mobilization, low-power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry hot pack therapy , intermittent traction and short waved therapy. But the management of symptomatic disease is still far from optimal [14][11][12][13][15]. First and foremost, the patient should be encouraged to take a minimum of bed rest the first 48 hours after being diagnosed with acute osteoarthritis.[14] (level of evidence 3A )
Exercise Programs
Neck support exercises are most efficient for mechanical neck disorders with or without headache. Manual therapies should be combined with exercise therapy for improving pain sensation and patient satisfaction. The findings of a review by H Sarig Bahat revealed relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck–shoulder musculature for chronic or frequent neck disorders.[14] (Level of Evidence 3A)
Neck pain is often caused by the upper trapezius muscle and is called trapezius myalgia. Exercise programs can target the painful trapezius muscle with simple and inexpensive training equipment. These exercises are dynamic exercises with controlled movements: lifting and lowering the dumbbell should be done in about 3 seconds, each repetition without sudden jerks or accelerations. The patient should use a weight that could be lifted for 8 repetitions (80% 1 RM). [8](level of Evidence 4)
The use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. No beneficial effects may be expected of stand-alone stretching exercises. [16] (Level of Evidence 1A)
A good exercise consists of at least two sets of 3 repetitions (ie, a total of 6 repetitions) with rest periods of 2 minutes between sets to avoid muscle fatigue. For all exercises, the heaviest weight that can be lifted for an 8-repetition maximum (8-RM) are used. [8](level of Evidence 4)
The following exercises can be used to lower the tensioning of the upper trapezius: [8] (level of Evidence 4)
Shrugs (SHR):
1. Starting postion: Stand erect, hold the dumbbells to the side
2. Action: Elevate the shoulders while focusing on contracting the upper trapezius muscle.
One-arm rows(ONE):
1. Starting position: Bend torso forward to approximately 30 degrees from horizontal with one knee on the bench and the other foot on the floor.
2. Action: Maintain one arm in extension to support the body on the bench. Meanwhile, pull the dumbbell toward the ipsilateral lower rib.
Upright rows (UPR):
1. Starting position: Stand erect and hold the dumbbells while the arms hang relaxed in front of the body.
2. Action: Lift the dumbbells toward the chest in a vertical line close to the body while the elbows are flexed and the shoulder abducted. (The elbows point out and upward.)
Reverse flys (REV):
1. Starting Position: Lay on your chest at a 45-degree angle from horizontal with the arms pointing toward the floor.
2. Action: Raise the dumbbells until the upper arms are horizontal, while the elbows are in a static, slightly flexed position (∼5°) during the entire range of motion.
Lateral raises (LAT):
1. Starting position: Stand erect and hold the dumbbells to the side.
2. Action: Abduct the shoulder joints until the upper arms are horizontal. The elbows are in a static, slightly flexed position (∼5°) during the entire range of motion.
Manual Therapy - Manipulations and Mobilizations
There is strong evidence that demonstrates that manual therapy was not significantly superior to other interventions like exercise, physical therapy, medication and short wave diathermy for relief of neck pain. However, patients who received manual therapy are significantly more satisfied with their care than patients who received any other single therapy. Furthermore there is a trend (found in 3 studies) showing that the combination of manual therapy with exercise leads to larger improvements in pain, disability and patient-perceived recovery than manual therapy alone. The combination of manual therapy and exercise may be useful in treatment of mechanical neck disorders. [9](Level of Evidence 1A)
Mobilization and/or manipulation used in combination with exercise are beneficial for persistent mechanical neck disorders with or without headache. A significant difference was found in reduction in pain, improvement in function and global perceived effect. Mobilization and/or manipulation as a stand-alone treatment were not beneficial. [16] (Level of Evidence 1A)
The case series by Yu H et al. suggests that symptoms of atlantoaxial osteoarthritis may be improved by upper cervical spinal manipulation combined with mobilization with a mechanical device called the S.M.A.R.T. adjuster This device consists of a lever-actuated mechanical jig and a pressure sensor so that it can detect tissue changes (temperature and density) thought to be a result of reduced spinal segmental motion. The device can transmit up to 20 lb/inch2 force impulse through a piezoelectric force sensor to mobilize joints. 10 patients were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. The frequency and intensity of cervical manipulations were set up on a case-by case basis, largely depending on patients' tolerance to the manipulation. The age of the patient, cause, duration, and course of the arthritis were all taken into consideration. To patients whose symptoms were at the initial stage or who were in the early stage of recovery from injury, higher frequency and lower intensity were usually applied. When the symptoms of the osteoarthritis were under control a different frequency of care, such as once a week, was used. [7] (Level of Evidence 3A)
Spinal manipulation has been shown to mobilize the facet joints and increase facet joint space, which not only relieves the pain caused by joint degeneration but also restores joint mobility and lessens the degenerative process.[11](Level of Evidence 1B) It is very important to know that chiropractic manipulation can only be provided to patients who present no neurovascular deficits and no acute injuries. Subsequent to the upper cervical HVLA manipulation, patients receive supplementary mobilizations of the upper cervical region.
Low-Power Laser Therapy
According to Ozdemir et al. low laser therapy can have a beneficial effect on pain and function. Pain, paravertebral muscle spasm, lordosis angle, the range of neck motion and function were observed. All these items showed a significant improvement. However the article indicates that further research needs to be done to determine the exact beneficial mechanisms of Low-power Laser Therapy[13][14]. (level of evidence 1B)
Monteforte P. et al found a non significant pain improvement in a assessment after 20 days. They also found a significant difference in the thickness of the subcutaneous soft tissue layer overlying the two superior trapezia. [12] (Level of Evidence 4)
Ozdemir et al conducted a study aiming to evaluate the analgesic efficacy of LPL therapy and related functional changes in COA. A placebo group and LPL therapy were evaluated (60 patients): pain, paravertebral muscle spasm, lordosis angle, the range of neck motion and function were observed to improve significantly in the LPL group, but no improvement was found in the placebo group. LPL seems to be successful in relieving pain and improving function in osteoarthritic diseases.[13]level of evidence 1B)
Pulsed Electromagnetic Fields.
During PEMF treatment, a pulsating electromagnetic field is produced. PEMF may promote the formation of collagen and human chondrocytes. In a study by Sutbeyaz ST et al., patients with cervical osteoarthritis lay on a mat for 30 min per session twice a day for 3 weeks. The whole body is treated by using a mat 1.8 x0.6 m in size. A mean intensity of 40 lT and a frequency range from 0.1 to 64 Hz was used. This therapy has a positive influence on pain levels, flexion and extension ranges and paravertebral muscle spasm. [14](Level of Evidence 1B)
The study by Trock et al. shows benefit from pulsed electromagnetic fields in painful osteoarthritis of the cervical spine. By the end of the treatment and one month later the experimental group has a better outcome in pain, pain on motion and tenderness than the placebo group. [12] (Level of Evidence 1B)
Infra-Red Stimulation of Local Trigger Points
Local heat seems to be particularly useful in treating osteoarthritis pain. Infra-red stimulation causes a short term pain relief. Important to keep in mind is that the stimulation is applied on the areas of higher tension, the trigger points.[15] (level of evidence 1B)
In a systematic review of Chow et al, RCT's were analyzed to confirm the positive effects of infra-red on neck pain. Significant positive effects were reported in four of five trials in which infrared wavelengths (λ = 780, 810–830, 904, 1,064 nm) were used. Heterogeneity in outcome measures, results reporting, doses, and laser parameters precluded formal meta-analysis. Effect sizes could be calculated for only two of the studies. They concluded positive effects are present, but more studies need to be performed to analyze parameters (duration, intensity,..). [15] (level of evidence 1A)
Massage is often used in clinical practice, for treating patients with neck and neck related problems. This although evidence about the clinical effectiveness is scarce, as seen below. If positive results are found, is mostly on the short or intermediate term.
A review of Ezzo J et al. included 19 trails where massage as a stand-alone treatment or as a part of a multimodal intervention have been examined. Because of inconclusive results of the trails, no recommendations for practice can be made. [13](Level of Evidence 1A)
The Cohrane review of Patel KC. et al included 15 trails. Because of the uncertain effectiveness of massage, no recommendations for practice could be made. Yet, massage for mechanical neck disorders as a stand-alone treatment was found to provide an immediate or short-term effectiveness or both in pain and tenderness. [15](Level of Evidence 1A)
In further studies the massage treatment need to be characterized (frequency, duration, number of sessions, and massage technique) and the long-term effects need to be assessed.[13] [15]
Short Term Results of Physiotherapy
The study of Hey et al. showed significant results of physiotherapy as initial conservative therapy of degenerative spine diseases. Improvement can be expected in sleeping, reading/writing, working/doing homework and carrying heavy things. The therapeutic modalities are joint mobilization, dry hot pack, intermittent traction, short-wave therapy and interferential electrical stimulation.[11] (level of evidence 1C)
Key Research
Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Bronfort G, Santaguida PL, Cervical Overview Group. Exercises for mechanical neck disorders (Cochrane review) Cochrane Database of Systematic Reviews 2015;Issue 1
Clinical Bottom Line
Osteoarthritis of the atlantoaxial joints can be idiopathic degenerative and posttraumatic. The prevalence of the osteoarthritis increases with age and is not gender dependant. Only a minority of the patients become symptomatic. Radiological presence/signs of atlantoaxial osteoarthritis do not correlate with the severity of the patients symptoms if those are presented. Those symptomatic patients complain mostly about unilateral neck pain occurring with the slightest head rotation and a painful audible crepitation with head rotation. There is evidence that physical therapy including neck support exercise programs, manipulation in combination with joint mobilization, low power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry-hot pack therapy, intermittent traction and short waved therapy have a beneficial effect on the recovery. There is no current research exists that compares the most effective therapy. Current evidence notes that manual therapy was not significantly superior to other interventions as exercise, physical therapy, medication and short wave diathermy for relief of neck pain. However, patients who received manual therapy reported being significantly more satisfied with their care than patients who received any other single therapy. Besides, they saw in three studies that there was a trend that manual therapy combined with exercise returned moderately larger improvements, although not statistically significant, in pain, disability and patient-perceived recovery than manual therapy alone. However, more research need to be done in this area that focuses on the most effective therapy treatments for this injury.
- ↑ Philip Conaghan et al. Osteoarthritis National clinical guideline for care and management in adults. Royal College of Physicians, 2008. (evidence level: 5)
- ↑ Serap Tomruk et al. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006 Feb;26(4):320-4. Epub 2005 Jun 29
- ↑ Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (level of evidence 2C)
- ↑ Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (evidence level: 4)
- ↑ A.Goel, A. Shah, Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: analysis of the management of 108 cases, journal of neurosurgery: spine, Jun 2010 / Vol. 12 / No. 6 / Pages 592-601 (level of evidence 2B)
- ↑ 37. Ak H, Özlem B, Aylin O. Effectiveness of gabapentin in unilateral atlantoaxial osteoarthritis as a cause of painful neck. World Neurosurgery, 2014. (level of evidence 4)
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (level of evidence 2C)
- ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (evidence level: 4)
- ↑ 9.0 9.1 9.2 9.3 A.Goel, A. Shah, Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: analysis of the management of 108 cases, journal of neurosurgery: spine, Jun 2010 / Vol. 12 / No. 6 / Pages 592-601 (level of evidence 2B)
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Liu K, Lü Y, Cheng D, Guo L, Liu C, Song H, Chhabra A. The prevalence of osteoarthritis of the atlanto-odontoid joint in adults using multidetector computed tomography. Acta Radiol. 2014 Feb;55(1):95-100. doi: 10.1177/0284185113492722. Epub 2013 Jul 22. (Level of Evidence 2B)
- ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 Badve SA, Bhojraj S, Nene A, Raut A, Ramakanthan R. Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population. Spine (Phila Pa 1976). 2010 Feb 15;35(4):434-8. doi: 10.1097/BRS.0b013e3181b13320. (Level of evidence 2B)
- ↑ 12.0 12.1 12.2 12.3 12.4 Lakshmanan P, Jones A, Howes J, Lyons K. CT evaluation of the pattern of odontoid fractures in the elderly--relationship to upper cervical spine osteoarthritis. Eur Spine J. 2005 Feb;14(1):78-83. Epub 2004 Jun 15. (Level of Evidence 2B)
- ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Betsch MW, Blizzard SR, Shinseki MS, Yoo JU. Prevalence of degenerative changes of the atlanto-axial joints. Spine J. 2015 Feb 1;15(2):275-80. doi: 10.1016/j.spinee.2014.09.011. Epub 2014 Sep 30. (Level of Evidence 2B)
- ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 14.11 Serap Tomruk et al. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006 Feb;26(4):320-4. Epub 2005 Jun 29.
- ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 BMJ Publishing Group Limited 2015, Assessment of neck pain. BMJ Best Practice. Retrieved fromhttp://bestpractice.bmj.com/best-practice/monograph/943/diagnosis/differential-diagnosis.html (Level of Evidence 5)
- ↑ 16.0 16.1 16.2 16.3 Glémarec J, Guillot P, Laborie Y, Berthelot JM, Prost A, Maugars Y. Intraarticular glucocorticosteroid injection into the lateral atlantoaxial joint under fluoroscopic control. A retrospective comparative study in patients with mechanical and inflammatory disorders. Joint Bone Spine 2000 jan (Level of evidence 2B)


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Cavo Astoria Retaurant
October 3rd, 2010
October 3rd, 2010
Jessica had her heart set on an outdoor ceremony in the garden but the whole week before the wedding it rained and rained and things didn't look good. So after much praying guess what? The wedding day was sunny and beautiful and Jessica had the outdoor ceremony she so wanted.
The bride hired a Peruvian flautist to play during the ceremony which was amazing and so beautiful!
The reception was beautifully decorated in fall colors. It was full of little details that the bride and her family went to alot of trouble to create. Like this beautiful seating chart
and these lovely programs:
The cake was made by the brides mom Lucy. It was beautiful and delicious!
Especially touching was the bride's dance with her mom. You could just feel the love between them as they danced to "You Lift Me Up" by Josh Groban. I don't think there was a dry eye in the house. I know I cried!
Congratulations Jessica & Lenin! So happy your day turned out to be everything you wanted and that we were able to be a part of it!


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Torch Trust is a Christian organisation with a worldwide vision for people with sight loss
Daily Bible verse and prayer topic - Thursday 21 November 2019
Blessed is the one you discipline, Lord, the one you teach from your law Psalm 94:12 (more daily Bible verses)
Pray for Paul Rhodes and Chich Hewitt as they lead the Manchester Diocese Disability Task Group (more daily prayer items)
Our online Daily Prayer Guide can be found on the Support Torch with Prayer page where there is an update to the Torch Prayer Phone.
God's new plans for Torch
Posted: 23rd September 2019
"For I know the plans I have for you," declares the Lord, "plans to prosper you and not to harm you, plans to give you hope and a future." Jeremiah 29:11
We have recently written to all our Torch friends to share important news about how we are developing the future ministry of Torch.
Please do read the full letter from our Chair of Trustees Marilyn Baker and CEO Julia Hyde.
Torch in brief
Torch Trust's aims can be summarised as enabling people with sight loss to discover Christian faith and lead fulfilling Christian lives.
Towards this end we provide Christian resources and activities for blind and partially sighted people worldwide. Our services are offered to all who experience sight loss, of all faiths or none, and including those with sight loss who have other disabilities.
Among our services, Torch provides Christian literature, including a free lending library and a range of magazines, in various accessible formats. We also promote Christian fellowship through over 60 local Groups across the UK. Our international arm involves Torch working in partnership with others and being involved in various projects, especially in Malawi which in turn serves the needs of blind and partially sighted people in various other African countries.
Torch Trust has a driving vision for people with sight loss, wherever in the world they may live. Our seven-fold charter is that every blind or partially sighted person may have the opportunity to:
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We produce two newsletters each year filled with updates on recently completed projects, upcoming events, changes to our governing board and staff, monthly meeting recaps, and much more. View our latest newsletter here or scroll to the bottom for a list of our past newsletters. Enjoy!
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How Can Executive Leadership Training Energize Your Visionary Leadership Skills?
Executive leadership training programs can sharpen and focus your strategic vision.
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In today's globally competitive economy, all professionals, supervisors, managers and entrepreneurs must participate in executive level leadership training.
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- 1) Map It - show them the avenue leading to bountiful opportunities and hidden treasures
2) Model It - reveal how all the moving parts will work together when you flip the switch
3) Diagram It - draw out the specs, structures, synergies and signposts behind the vision
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Executive leaders must practice and master the ability to focus their attention and concentrate their energies on:
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=> Deploying reliable, failure-resistant systems for producing successful individuals and outcomes;
=> Turning their management-dominated strategic planning exercises into a "total employee involvement programs"
In this Age where imaginative applications of Knowledge are the primary source of competitive advantage, it is foolish to rely on anything less than executives who expertly inspire and leverage their people's potential through strategic, visionary leadership practices.
Encourage Them! The acid test for executive leadership training programs reveals itself through these criteria:
- Do leaders exhibit the kinds of desirable personal, organizational and societal traits, values and work patterns within their strategic leadership behaviors?
- Are visionary leadership attributes - such as, continuous learning and growth, an eagerness or greediness for new things and a unshakable commitment to embrace broader perspectives - embedded in this executive leader's DNA?
- Which components, if any, of your leadership agenda are driven by the human capital developmental priorities of your strategic visions?
Without a vision, the people perish but every vision needs to be supported by hope which at its root describes:
- - Behavioral models which honestly reflect a set of high ideals,
- An open exchange of, interactions with and search for new ideas,
- A daily agenda that actively promotes excursions into self-discovery, professional education and community enrichment
Without all these seeds, your organization's strategic vision will find itself bleeding the emotional, spiritual and psychological strengths it needs to survive, flourish and thrive.
So the question remains: how does your executive leadership training programs develop your strategic leadership skills, visionary leadership competencies and proficiency in enabling, educating and enriching your human capital assets?
It's simple, really. You use all the principles, concepts and techniques described in this article to educate, train and develop the visionary leadership skills of your managers and professionals!
Copyright © 2008, Mustard Seed Investments Inc., All rights reserved.
Bill Thomas conducts executive level leadership training programs which develop Awesome Leaders and Innovative Leaders - he helps professionals, managers, supervisors, executives, entrepreneurs and directors by providing focused leadership subjects, coaching and consulting support, practical exercises, tons of powerful tools and energetic interactions with clients. His cost-effective training workshops, programs and innovative leadership solutions are guaranteed to maximize the returns on your investment.
Awesome Leadership Programs and
Innovative Leadership Training Solutions


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Mailing lists are an important means of communication among users and developers of OpenBSD. With the exception of announce, the lists are not moderated. We deliberately restrict the number of different mailing lists. This helps reduce the amount of cross-posting and makes sure that the information gets distributed to a wide audience.
Note that if you are sending mail from a dynamic IP address, you will probably not be able to post to the mailing lists. In this case, you should use a smart host mail configuration that utilizes your ISP's mail server. See the examples in smtpd.conf(5) for how to do this.
To subscribe to a given list, send mail to firstname.lastname@example.com with a message body of "subscribe mailing-list-name" (where mailing-list-name is the name of your preferred list).
For further assistance, send a message body of "help" to email@example.com and you will receive a reply outlining all your options. Your domain must resolve properly or the mail will not go through!
As an example, if you were going on vacation for two weeks and didn't wish to come back to several thousand emails, you can disable message delivery by the mail server for the time of your vacation and have delivery automatically resume upon your scheduled return using the command:
This will suspend your subscription to all mailing lists for 14 days (-14d). More details and options can be seen on the Majordomo overview page.set ALL nomail-14d
for daily digests of the misc list, and weekly digests of the source-changes list. Yes, multiple commands can be placed in one Majordomo email.set misc digest-daily set source-changes digest-weekly
The insomniac at benzedrine.ch maintains the pf list for people using the OpenBSD packet filter. To subscribe, send an email with the message body of "subscribe" to firstname.lastname@example.com.
To subscribe, visit the URL at: http://groups.google.com/group/openbsd-japan
To subscribe, visit the URL at: http://groups.google.com.mx/group/OpenBSD-Mexico
To subscribe, send an empty message to firstname.lastname@example.com


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According to a new study done by University Professional and Continuing Education Association (UPCEA), Pennsylvania State University and Pearson, millennial students tend to lean towards badging and certificate programs as opposed to the traditional bachelor's degree.
The study, titled "Demographic Shifts in Educational Demand and the Rise of Alternative Credentials" includes research conducted from 190 institutions, including community colleges (11 percent), baccalaureate colleges (12 percent), master's colleges or universities (27 percent), and doctorate-granting universities (50 percent). Of those surveyed, 61 percent of them were public institutions. Overall, the research revealed that offering alternative credentials, such as digital badges, certificates, and micro credentials, have become popular, with 94 percent of institutions reporting that they offer this.
Digital badges are online representations of skills learned by students, typically with visual iconography; certificates are usually issued by educational institutions to students who have completed significant programs of study that do not culminate in a specific degree; while micro credentials are digitally presented certifications providing evidence that an individual has mastered a specific skill or area of knowledge that demonstrates their learning.
Director of UPCEA's Center for Research Marketing Strategy, Jim Fong; director of the Center for Online Innovation in Learning and a professor at Penn State, Kyle Peck; and senior director of business development at Pearson's Acclaim, Peter Janzow all conducted the study. They have also found that:
* One in five institutions offers digital badges
* Digital badges are most commonly offered in business-related domains
* Institutions with corporate engagement value alternative credentialing more than institutions that did not
* Sixty-four percent of those surveyed agree that their institution sees alternative credentialing as an important strategy for its future
According to Fong, "The degree will always be an important credential, but it won't always be the gold standard. As millennials enter the prime years of their career and move into positions of greater power, we'll see more alternative credentials for specific industries and possibly across the board. Higher education institutions, especially those in our survey, are showing that they are being progressive with workforce needs." For more information, please visit UPCEA's website for more information.


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A forum about Atari 16/32 computers and their clones. This forum is in no way affiliated with Atari Interactive.
Moderators: Mug UK, Adrenalin, Moderator Team
troed wrote:Don't listen to the haters. It's great that there are still NOS Ataris out there, with matching box. The price is correct when a buyer and a seller agree - and everyone else's opinion doesn't matter at all.
Nice machine!
Users browsing this forum: thomas3 and 7 guests


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Apple Releases New Cheaper iPod Touch 5 With 16GB Of Storage/
Today, Apple has introduced a cheaper iPod touch 5 with a 16GB storage capacity for only $229. The new model is available now, and still has the same 4-inch Retina Display, ultra-slim aluminum build, a dual-core A5 chip and all the usuals as the more expensive 32GB and 64GB models; even a set of EarPods. The catch? It lacks a rear-facing camera (you've got an iPhone for that no?), the loop strap and it only comes in one color, silver. Still, great news for minimalists all around. In a move towards offering more affordable products that will enable more people to enjoy the fruits of Apple, it is rumored that the company will eventually release a more affordable iPhone model as well. This is a great start so far.


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UN scribe Ban Ki-moon and U.S. Secretary of State John Kerry have restated that a political solution was the only solution to end the ongoing crisis in Syria.
The duo who spoke with reporters at the UN Headquarters in New York on Thursday, noted that they would step up efforts to facilitate dialogue among all parties in the Syrian conflict.
"More than 100,000 people have been killed, and millions of people have either been displaced or have become refugees in neighbouring countries.
"We have to bring this to an end. Military and violent actions must be stopped by all the parties and it is thus, imperative to have a peace conference in Geneva as soon as possible, as initiated by Mr. Kerry and Mr. Lavrov," the secretary-general said.
He added that he and Joint Special Representative Lakhdar Brahimi would spare no effort to convene the meeting as soon as possible.
The UN chief commended Kerry's leadership and consistent engagement to revive the peace process for a two-State solution.
He urged the leaders of Palestine and Israel to "seize this opportunity and respond positively and courageously so that the two-State solution could be realised as soon as possible."
In May, following talks in Moscow between Russian Foreign Minister Sergey Lavrov and Kerry, the two countries announced they would work together to find a political solution to the Syria crisis, and agreed to convene an international conference aimed at achieving this goal.
However, a date for the conference has not yet been set and talks are continuing on the best time for it to be held, who should participate, how it should be structured and some of the questions to be discussed.
"There is no military solution to the crisis in Syria, there is only a political solution and that will require the leadership to bring people to the negotiating table," Kerry said, adding that he and Lavrov remain committed to make the Geneva meeting happen.
On the Great Lakes and the situation in the Democratic Republic of the Congo (DRC), both Mr Ban and Mr Kerry underlined the need to follow the Peace, Security and Cooperation Framework, and reiterated the commitment of their Special Envoys in the region to work together.
The Framework was signed in February by 11 African leaders, and aims to end the cycles of conflict and violence in eastern DRC and to build peace in the wider region.
Ban also thanked Kerry for the U.S. government's support for initiatives that seek to advance sustainable development and combat climate change.


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Davenia Jones Lea has a doctorate degree in education with over twenty years of experience working with families of children with disabilities, as well as in higher education. She has extensive experience working in the family-life ministry within her church, where she has facilitated couples support groups and counsels new mothers, including young and single mothers. She also conducts workshops, seminars and retreats for women and families related to topics such as parenting, marriage, in addition to the topics addressed in Naked and Unashamed.
Davenia's madly in love with her husband, Derrick of twenty-one years and is grateful for the gift of her two adult children. She is committed to living a God directed life and is equally committed to living her life free and without shame.
Pieces of Me
Fusce at tincidunt ligula, rhoncus placerat ante. Nullam aliquet mauris ultricies mi sagittis malesuada. Phasellus in ligula eget eros eleifend condimentum.


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Festive Winter Box
Designer Dries Clear Adhesive, 159723
Metal Tip for Adhesive Bottles, 352854
Memento Dye Ink Pad - Tuxedo Black, TSMP900
Deluxe Flower Shaping Kit, HCST1-401
Scor-Pal Measuring & Scoring Board, 173842
Glue Tip Pins, PIN6
Rajni Chawla's Crystal Clear, PGM15015
Window Frame Die, HCD1-7148
Winter's Eve Paper Collection, HCDP1-281
Window Box Elements Die, HCD1-7150
Other Products: Westcott Brand Trimmer/Scissors, Copic Sketch: G21, G24, Jewelry BoxWindow Box Fillers Cling Stamp Set, HCPC-3795
For EZ tips to create your own warm and cozy winter scene click here
Instructions: Take your patterned paper and cover the entire jewelry box, adhere using dries clear glue. Once complete you will fussy cut the deer, two sentiments and the poinsettias from the Winters Eve collection. You will use one sentiment and the fussy cut deer on the inside of the Score and fold bottom paper of deer. Glue folded part to music box. The fussy cut poinsettias will be shaped into 3D flowers. Cut a total of 6 flowers from the paper, add glue and then apply some of the Crytal Clear along the edge of each flower petal.
Stamp leaves from the Window Box Fillers HCPC-3795 and Window from HCPC-3794 and diecut with coordinating dies. Color using Copic markers. Shape using Deluxe Flower shaping Kit. Die cut window box from designer paper and window box border from white cardstock. Fold tabs for window box and adhere together using dries clear glue, creating the shaped box. Adhere border to window box. Adhere Window directly onto front of Music Box. Arrange all pieces as shown and adhere.


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Star Fluxx Review/
It's time for another game review - and this time it isn't Munchkin related! I mentioned this in my 2012 Christmas Guide, but I recently picked up a new fun game called "Star Fluxx". Check out the video above for my review of the game. It's a really simple game that I think many of you will enjoy!


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A great deal of the photos available on this site are the work of a very talented woman, Darcy Copeland.
Volunteering for CRFR as both a Chaplain and a photographer. She has donated much of her time and talent to capture emergency scenes and the people that work on them.
For more information about her work, visit here Facebook Page at Captured Moments Photography.


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Private research institutes - accreditation
Businesses and private-law establishments must have an accreditation as a private research institute in order to:
- hire third-country national researchers in order to carry out research projects;
- or benefit from the Industrial Fellowships programme by the National Research Fund (Fonds national de la recherche - FNR).
Accreditations are issued by the Ministry of the Economy which holds a list of accredited establishments.
Who is concerned
Accreditation is required for any business or institute governed by private law which:
- intends to hire a researcher from a third country;
- intends to hire a researcher from a third country who is already legally established in Luxembourg;
- intends to hire a researcher from a third country who has already concluded a host agreement in another EU Member State and intends to stay more than 3 months in Luxembourg;
- wishes to obtain funding from the Industrial Fellowships programme for research work carried out by researchers working on a PhD.
Businesses that do not intend to take advantage of the benefits listed above are not required to apply for accreditation as a private research institute in order to carry out research work.
A private Luxembourg research institute must:
- be located in Luxembourg;
- carry out or plan to carry out research work, namely:
- basic research: this covers experimental or theoretical work mainly carried out with the purpose to acquire new knowledge on basic phenomena or observable facts, without any practical application or use being directly envisaged;
- industrial research: this covers planned research or critical surveys aimed at acquiring new knowledge and capabilities in order to develop new products, procedures, services, methods or planning, or to bring about a significant improvement in existing products, procedures, services, methods or planning. It includes the creation of elements for complex systems necessary for industrial research, notably for the validation of generic technologies, excluding prototypes;
- experimental development: the objectives are the acquisition, association, formulation and use of scientific, technical and commercial knowledge or other existing knowledge in order to carry out projects, create devices or drawings or models for the design or development of new, modified or improved products, procedures, services, methods or planning.
The development of prototypes or the running of commercially exploitable pilot projects also depends on experimental development when the prototype or the pilot project are essentially the finished commercial product or the final process and when it is too costly to produce it for demonstration and validation reasons only.
How to proceed
Application for accreditation
The research institute must submit an application for accreditation as a private research institute to the Ministry of the Economy.
Applications must be accompanied by:
- audited annual accounts for the past 3 financial years (except for recently created businesses);
- any additional information deemed necessary for the evaluation of the accreditation application.
Accreditation is generally granted for a period of 3 to 5 years, except for recently created businesses, for which the period of validity is 3 years.
List of accredited private research institutes
- Actimage S.A.
- Agence pour la Normalisation et l'Économie de la Connaissance (ANEC)
- Allen & Overy s.e.c.s.
- AMA MUNDU Technologies S.A.
- Amersil S.A.
- ANG S.à r.l.
- ArcelorMittal Belval et Differdange S.A.
- Artec Europe Sàrl
- Ballinipitt architectes urbanistes S.A.
- Banque et Caisse d'Epargne de l'Etat
- Black Swan LUX S.A.
- Blue Horizon Sàrl
- Braingineering Technologies Sàrl
- Brainiact s.à r.l.
- Brasserie Nationale S.A.
- CBN Technologies Sàrl
- Cebi Luxembourg S.A.
- Ceodeux S.A.
- CERATIZIT Luxembourg S.à r.l.
- Choice Technologies Luxembourg sàrl
- Cooperations ASBL
- Cyberhedge Europe Sàrl
- DataThings Sàrl
- Deloitte Tax & Consulting
- Delphi Automotive Systems Luxembourg
- eBus Competence Center Sàrl
- Eethiq Advisors sàrl
- Espeem Sàrl
- Euro-Composites S.A.
- European Centre for Certification and Privacy S.A.
- ExaMotive S.A.
- e-Xstream Engineering sàrl
- Fast-Track Diagnostics sàrl
- Ferrero Trading Lux S.A.
- Flen Health S.A.
- FMR s.àr.l.
- Fondation Alphonse Weicker
- Fonds pour le développement du logement et de l'habitat
- Foyer Assurances S.A.
- Frontier Connect Sàrl
- GCL International Sàrl
- GomSpace Luxembourg Sàrl
- Goodyear S.A.
- Gradel sàrl
- Healthcast S.A.
- Husky Injection Molding Systems Luxembourg IP Development sàrl
- InCert G.I.E.
- Information Technology for Translational Medicine (ITTM) S.A.
- International Lacquers S.A.
- ispace Europe S.A.
- itrust consulting
- Kuehne + Nagel s.à r.l.
- Lindab S.A.
- Logos It Services S.A.
- LUCA - Luxembourg Center For Architecture
- LuxAl S.A.
- LuxMobility Sàrl
- Luxplan S.A.
- Luxscan Technologies Sàrl
- Luxspace
- Mahle Behr Luxembourg s.àr.l.
- Max Planck Institute Luxembourg
- Motion-S S.A.
- Natura4Ever S.A.
- Next Gate Capital S.A.
- neXus Luxembourg sàrl
- Nexxtlab S.A.
- Objectim Sàrl
- Olamobile s.à r.l.
- Oriskany s.àr.l.
- pEp Security S.A.
- PM-International AG
- ProNewTech S.A.
- PwC Société Coopérative
- RSS-Hydro Sàrl-s
- RTC4Water S.à r.l.
- SES Engineering (Luxembourg) s.à r.l.
- SES Techcom S.A.
- Sisto Armaturen S.A.
- Société de la Bourse de Luxembourg
- Space4environment s.à r.l.
- SPARC Industries s.à r.l.
- STATEC Research asbl
- Telindus
- Textilcord Steinfort S.A.
- Trendiction S.A.
- Witry & Witry S.A.
Forms / Online services
Agrément RDI - organisme de recherche privé
Demande d'agrément - organisme de recherche privé
Who to contact
General Directorate for Research, Intellectual Property and New Technology19-21, boulevard Royal
L-2449 Luxembourg
Postal address :
Phone : (+352) 2478-2478
National Research Fund2, avenue de l'Université
L-4365 Esch-sur-Alzette
Postal address :
Phone : (+352) 26 19 25-1Fax : (+352) 26 19 25-35


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GEOPOLITICS IS POLITICS taking place in regard to geographical circumstances, territorial relations and aspirations of political entities. It derives from the spatial settings of place as well as from territoriality as a universal dimension of human (and animal) behavior. While the spectrum of geopolitical action is very wide, it is never just derived from "geographic imperatives." There are always underlying motivations, constructions and lines of thinking behind geopolitics, whether we speak of geopolitical theories or geopolitical action. In order to understand the relational and proportional settings of contemporary geopolitics, it helps to construct some kind of picture of the asymmetric "geopolitical ideologies" that influence the motives and ideas behind the geopolitical activities of various states and other political actors.
At the same time, geopolitics should not be confused with the field of POLITICAL GEOGRAPHY. Both disciplines have in common the search and identification of an area of study that concerns the connection and mutual interaction between geography and politics. Political geography deals with the study of the existing relations between spatial facts and the political processes, and therefore constitutes the spatial analysis of political phenomena. It concerns the spatial attributes of the political process or can be seen as the study of existing relations between spatial facts and political processes. Geopolitics, on the other hand, is an approach to international politics that insists on the significance of geographic territory and its resources. It represents the study of the geographic distribution of power among the states of the international system, paying particular attention to the rivalries of the major powers. From a slightly different point of view, geopolitics could be seen as an expression of the foreign policies of states, where those policies are determined by the state's location, natural resources, and physical determinants. Thus, geopolitics and geopolitical analysis constitute the study of international politics seen from a spatial or geocentric perspective. Where political geography deals with the interaction of geographical factors and politics, the interactions of political power and space, geopolitics tries to provide a geographic interpretation of these events by studying the geographical aspects of political phenomena.
A Swedish political scientist, Rudolf Kjellen, originally coined the term geopolitics in 1899. Kjellen viewed the state as a living organism and, in developing his ideas, saw geopolitics as the study of the state as a geographic organism whose spatial phenomena could be a land, a territory, a space, or a country. Kjellen believed that in order for a state to be strong, its government had to put in practice five complementary types of policies in order to be successful in its natural expansion. For Kjellen, the aim of the discipline was to demonstrate the role of the geographic characteristics in the conception of the state and the practice of statecraft to the statesman and decision maker.
According to Friedrich Ratzel, the state is a territorial entity with two essential coordinates: the space (raum), which he viewed as the total surface or aerial extent of territory, and the position (lage), which he referred to as the situation of the territory in relation to other states. Ratzel was also interested in two other ideas: the concept of space itself, namely the sense and meaning of space, and what he called vital space.
There is one definition of geopolitics that seems to be particularly well expressed. In the words of Osmo Tuomi, the geopolitics that emerged in the last decades of the 20th century is by no means comparable to the old framework and theoretical points of view, namely the eternal confrontation between sea power and land power developed during the late 19th century and the first half of the 20th. For Tuomi, theoretical geopolitics studies the relation between physical space and international politics, develops models for the spatial division of the world into cooperating and competing parts for historical, economic and political reasons, and analyzes how the participants interpret the political, economic, and military consequences of this division. The geopolitics of a state or other territorially defined society relates to its pursuit of geographically dimensioned aims that are connected with its economic and political position, security and culture.
With the end of World War II, new perspectives emerged for the study of geopolitics and political geography. The international system in the postwar period changed dramatically the notion of the balance of power and introduced strategic bipolarity and nuclear deterrence, concepts responsible for the ideological, political, cultural, and geographic confrontation between the two superpowers and the respective spheres of influence and blocks of allies. It was during this period that geopolitical theory cut drastically with the international situation that had prevailed up to that time, and the realities of the world situation were constantly assisting the development of new weapons, strategies, and techniques for conducting war.
The resurgence of both political geography and geopolitics began in the late 1960s and early 1970s as they ceased to be mere instruments in service of the military establishment/sphere and started to be objects of analysis by academics and researchers who wanted to construct critical reasoning and discourses with respect to the disciplines in question. The renaissance has been particularly manifest after the end of the 1980s, compared with the exclusion and distancing that it suffered after 1945 and for approximately three decades thereafter.
As one legitimate area of study, geopolitics and political geography deal with complicated if not problematic issues like GLOBALIZATION, deterritorialization through constant flows of information and finance, and transnational phenomena that transcend the boundaries of states and seem somehow to erode the concept of sovereignty itself.
In some respects, we live in a world that is becoming boundless, without physical and territorial borders, that bases itself on an increasing, more frequent, and perceptible interdependence among players. In this sense, some authors speak about the end of geopolitics because of profound impacts created by economic globalization. Information technologies and communication are progressively forming and reforming domestic politics and the foreign relations of states, raising doubts about the existence of borders, boundaries, territorial demarcations, and sovereignty itself.
Another major change in the study of geopolitics and geopolitical analysis started in the late 1980s and continued throughout the 1990s: Critical geopolitics. This line of study demonstrates that geopolitical issues and themes can be found in popular culture, movies, or mass media, that is, the press, TV and radio. These same issues are therefore seen as important forms of popular geopolitics. In comparison to formal geopolitics, the insight of critical geopolitics tries to determine in what manner and to what extent geographic labels do not imply some strong causal relation between physical geography and the behavior of the state and its political structures.
For some theorists, critical geopolitics takes issue with the traditional theories of political geography and opposing positions of geopolitical theories by analyzing their discourses and their role in spatial formation and development. In order to achieve an alternative form of geopolitics, one that intends to serve as the equilibrium in the hegemonic balance, the critical approach offers an examination of the suppositions that sustain particular geopolitical constructions, that is, production and use of geographic knowledge in various orders of power and space. In doing so, critical geopolitics tries to uncover the hidden geographical assumptions in foreign policy decisions and actions.
Following the fall of the Berlin Wall and the demise of the old Soviet system in 1991, a new phase in the international system of states began to take form, thus paving the way for the end of communism as a socioeconomic doctrine and a new orientation in foreign policy. The revival of geopolitics and political geography after years of relative neglect has highlighted primary concerns such as the role of geographical scale in establishing political identities. New threats to world security emerged, like regional conflicts, violent nationalism, religious fundamentalism, and sharp inequality between the rich north and the underdeveloped south. Some authors believe we live now in a more unpredictable and unsafe world. The disintegration of the Soviet empire has created a vacuum on the huge landmass that was Mackinder's HEARTLAND. And that heartland was also the region that in the past was the heart of the country with which the United States was struggling for global primacy. Geopolitics has once again gained special attention from Russian scholars and policy makers.
And once again, the concept of the heartland is retaining its credibility among Russian authors. Here is demonstrated the high interest in geopolitics, where the Eurasian theory provides a simple definition of the belief that RUSSIA is a unique power and does not need to Westernize in order to "obtain" and reach modernity. At the same time, the orthodox version of geopolitics means the Eurasian heartland is, in geographical terms, the milestone for the formation of an anti-Western movement, whose aim once again is to ultimately expel the "Atlantic" influence from Eurasia.
Today, geopolitics is a concept built on a plurality of issues within the theoretical framework of international relations and its study. In a widely interdependent and rapidly transforming world characterized by extremes in complexity, geopolitical perspectives can be very useful in defining the international system. This is particularly so with regard to the extent to which geopolitics is able to provide useful explanations of, as well as point out barriers and obstacles to, stable geospatial relations.
In this sense, geopolitics should be taken seriously, for it constitutes in itself a social element and a technological reasoning that helps in the construction of our images of the world. According to John Agnew, this imagination has provided meaning and rationalization to the practice of geopolitics to the extent that it has defined the ideological space from which the geographic categories upon which the world is organized and work are derived.
Geopolitics and political geography then simultaneously justify and legitimate a confrontation like in the days of the Cold War or give a picture of the inequalities that characterize the present (and past) world economy with regard to the representations of a world without limits, borders and boundaries. In the present state of the world, frontiers and borders seem to vanish because of the changes around the notion and function of territoriality. This points as well to the processes of globalization, a term highly used (and abused), but also a sometimes ill-defined one that can confuse all forms of economic, political, and cultural theories. The functions of the border and the sovereignty of the state are rendered less important and are therefore reduced to a more irrelevant perspective.
In a sense, geopolitics attempts to explain why some countries have power and other countries do not. This basic focus is clearly not new to the modern world. For as long as there have been human societies, there have been groups with power and control and those without. In many regards, this social psychological view of human spatial behavior can be seen as a history written in the language of territory and territoriality, both of which are natural expressions of humans as biological forms.
The special connection between the spatial qualities of countries and international relations has been observed since the Greeks. The Greek geographer and philosopher Strabo believed that geography was destiny, and that the presence of a given set of geographical circumstances automatically led to some form of political order.
The ancients were true ecologists, for they assumed a strong organic relationship between environment and society. In his book The Politics, Aristotle remarked on the impact of climate on human character and, ultimately, politics by indicating that it requires no stretch of logic to see geography and topography as both antecedent to and resultant of climate. But not everyone agreed. Writing in the 16th century, Jean Bodin took exception to the Aristotelian belief in the dominance of geography, arguing that reason, as exercised by statesmen, could overcome the tyranny of geography. Not long after, however, Napoleon Bonaparte returned to the original view, with a bold belief that the politics of a state is its geography.
The formal link between geography and political science that we drawn upon today began a little more than 100 years ago, when the idea of geography being destiny received new emphasis and a name (geopolitics) from Rudolph Kjellen, a Swedish political geographer. Under the general influence of the Age of Reason and a belief that science could be applied to benefit human society, Kjellen sought a science of international politics grounded in empirical bedrock. And for Kjellen, what better bedrock could be found than geography? In short, Kjellen's motivation was bound up with the contemporary conviction that serious inquiry needed to be linked to science rather than to the traditional conception of the humanities.
In 1890 Alfred Thayer Mahan wrote The Influence of Sea Power upon History, spelling out the necessity of sea power in facilitating trade and peaceful commerce. Mahan, therefore, believed that the country that could control the seas possessed the greatest power in the world. Thus, the development of a strong navy was an essential ingredient to a powerful state in addition to the country's location. Geographically, this meant that the country with the most power would be the one whose relative location was accessible and connected to other areas via a long coastline and good harbors. Mahan also saw the expression of this power as belonging north of the Suez and PANAMA CANALs.
The late 19th century was a period where the social sciences began to embrace the notions first identified by Charles Darwin when he wrote Origin of Species. This evolutionary approach took hold in many schools throughout Europe, particularly in Germany, which believed in a kind of social Darwinism as a working explanation for the evolutionary development of the states of the world, European countries (GERMANY) being the ultimate expression of the theory. The Germans became instrumental in developing this new idea into the field of geopolitics (geopolitik) and modern statecraft. In 1897, German natural scientist Friedrich Ratzel developed his "organic theory," contending that the state is like an organism that is attached to the Earth and that it competes with other states in order to survive. Further, like all living organisms, the state needs living space or Lebensraum in German.
Also in the late 19th century, Sir Halford MACKINDER proposed what has become the most widely discussed concept of geopolitics. Mackinder was interested in political motion, observing that the spatial distribution of strategic opportunities in the world was unequal. In his 1904 book Democratic Ideals and Reality, Mackinder developed his thesis with a disregard for Mahan's theory, suggesting that advances in technology were forcing a reevaluation of both spatial concepts and military strategies. As an example, he indicated that with the development of railroads, countries no longer needed to depend on the navy to move large armies. Accordingly, Mackinder believed that the focus of warfare would shift from the sea to the interior portions of countries and continents; something he called the HINTERLAND.
Mackinder then developed the idea of a "pivot area," located in the northern and interior parts of the Eurasian continent where the rivers flow to the Arctic or empty into salt seas. This area would be pivotal, he believed, as it would be easy to defend and hard to conquer. In later works, he began to refer to the pivot area as the "heartland," and devised his famous Heartland Theory. According to this theory, Mackinder believed that "He who controls the Heartland controls the World Island (Eurasia and Africa) and he who controls the World Island, controls the world."
Another German, Karl Haushofer, was a leading proponent of Mackinder's Heartland Theory and developed a theory around the idea of pan regions. Haushofer divided the world into three pan regions, blocs of power, based on the complementarity between North and South. His ideas represent an early conceptualization of the CORE AND PERIPHERY concept, where a northern core would be connected to a southern periphery. The three pan regions were Anglo-America with Latin America as the periphery; Europe (which he saw as controlled by Germany) with Africa and INDIA as peripheral areas; and JAPAN and its periphery, Southeast Asia. After World War I Rudolf Hess heard Haushofer's lectures and later introduced him to Adolf Hitler, who ignored the subtleties of Haushofer's teachings and used these geographic theories to advance the Nazi cause.
After World War II the study of geopolitics fell into disrepute because of its association with Nazi Germany and the fact that geopolitical theory ascribed a single cause to the success or failure of a country and that did not take into consideration human choice. This was known as determinism, later to be more fully developed as environmental determinism with geographic factors as the foundation for "environment."
Nicholas Spykman was a proponent of this environmental determinism approach, integrating economic, political, and military points of view into the theory. According to Spykman, states with locations north of the equator would always be more important than those south of the equator. Spykman also disagreed with Mackinder's Heartland Theory, believing that both sea and land power were important. In advancing his ideas, he believed that the real potential of Eurasia was in the "inner crescent," a region that included Western Europe, the MIDDLE EAST, South Asia, Southeast Asia, and the Far East. He called this region the Rimland, suggesting that its importance lay in the fact that the region had access both to the sea and to the interior regions. Spykman extended Mackinder's reasoning on the importance of the Heartland by stating: "Who controls the Rimland rules Eurasia; who rules Eurasia controls the destiny of the world."
During the Cold War years, policy makers relied on the Rimland Theory as justification for the policy of CONTAINMENT, that is, at stopping the spread of communism. Unfortunately, this led the geopolitics movement in America to take on highly simplified and distorted views whose primary purpose was to serve political ends. Geography was somehow pushed out of the geopolitical equation during this period, when it like economics and other social sciences, began to seek more refined scientific status through mathematics and the development of regional science. Practicing geopoliticans were now chosen from such fields as international relations and history, sometimes even from the military, but not from geography. Geography meant distance, size, shape, and physical features that were all static. The idea of geography as spatial patterns and relations that reflect dynamic physical and human processes was absent.
In an extension of conceptual ideas first developed by Mahan for sea power and later by Mackinder with reference to railroads, A.P. de Seversky, writing in Vitory through Air Power, believed that the development of air power made land battles obsolete. His contention was that whoever controls the skies would control the world. At the time of his writing, the United States and the Soviet Union were the two most important air powers. He used an azimuthal equidistant projection centered on the North Pole to show the air dominance of the two countries. He went on to indicate that there was an area of intersection visible on the map that he called the "area of decision," and that whoever controlled this area would be the dominant geopolitical power in the world.
During the 1970s, Immanuel Wallerstein developed a world-system theory of geopolitics, where the world-system was a social system having boundaries, structures, member groups, rules of legitimization, and coherence.
According to Wallerstein, there were two varieties of this so-called world-system. One could be viewed as comprised of a world empire where there is a single political system over most of the area. In the other form, there could be several subsystems within the world-system, but no single political system existing equally throughout the overall space.
Wallerstein used economics as the cohesive factor in his world-system theory and saw the world economy as the base upon which the world-system was built; something he believed took original form in Europe during the 16th century and was made possible by a division of labor that was both functional and geographical. Within this world-system Wallerstein identified three geographic areas: core states, peripheral states, and semiperipheral states. The advanced countries of the world economy represented core states. They all were believed to have strong state structures, national cultures, and highly integrated populations.
Within the model, trade, technology, and finance connected the economic powers as core states whereby they were also exploiters of the periphery. Peripheral states were weak and typically either colonial states or states with relatively low degrees of autonomy. The third region was comprised of semi-peripheral areas, those places that act as a buffer between the core and the periphery. As a reflection of determinism, Wallerstein believed that the world-system was already fully developed by the 1950s. As such, no country would be able to enter the system and successfully compete, and those countries currently in the periphery would probably never be able to catch up.
The spatial patterns geographers see in the world today are difficult to conceive of as being containable within national boundaries. The world has become an interdependent system where the nation-state is part of a shared area. One of the proponents of this theory is Saul Cohen, who wrote Geography and Politics in a World Divided. Cohen divided the world into geostrategic regions, one Maritime Realm, which is dependent on trade and has an external focus, and a Eurasian Continental Realm, which is continental in composition with an interior focus. Within each realm there is a further subdivision into first-order states (the ones that are the most powerful). According to Cohen, Japan, the United States and the European Community represent the current first order states within the Maritime Realm, while CHINA and the Soviet Union are the first-order states within the Continental Realm. Cohen's model also included what he called shatter belt states, which separate the realms or serve to separate regions within the realms.
There were also a group of independent states such as PAKISTAN, INDIA, THAILAND, and VIETNAM, and gateway states that acted as linkages between realms and regions. And finally, Cohen identified states that are asymmetrical. That is, states that are in a region but behave quite differently from the others in the same region.
Geopolitics analyzes politics, history and social science with reference to geography. Although U.S. diplomat Robert Strausz-Hup's popularized use of the term (for English audiences), the discipline gained most of its attention through the work of Sir Halford Mackinder and his formulation of the Heartland Theory. In January 1904, he introduced his paper "The Geographical Pivot of History" to the Royal Geographical Society. The paper initiated the onset of a new geopolitical era: a method of political analysis, which stressed the importance of geographic factors in determining national interests and international relations.
He questioned traditional perceptions, suggesting that, in the long run, land power was superior to sea power, and he revised the prevailing Eurocentric view of history. During his lecture, he asked his London audience to "look upon Europe and European history as subordinate to Asia and Asiatic history, for European civilization is, in a very real sense, the outcome of secular struggle against Asiatic invasion."
This theory involved concepts directly opposed to those of Mahan about the significance of navies in world conflict. The Heartland Theory hypothesized the possibility that a huge empire might to be brought into existence that did not need to use coastal or transoceanic transport to supply its military industrial complex.
If this were so, then such an empire could not be defeated by all of the rest of the world together if they joined against it. The basic notions behind Mackinder's theory involved a change in thinking where the geography of the Earth was being re-divided into a new variation of the notion of the "old world" (most of the Eastern Hemisphere) and the "new world" (the Western Hemisphere and Oceania). The difference was that the archipelagoes that were traditionally able to defend themselves using naval power, Great Britain and, prospectively, Japan, were taken from the old world (the world island), where they had been major players, and added along with the PHILIPPINES, INDONESIA, SRI LANKA, and MADAGASCAR to another part of the world now renamed the "periphery."
The other world islands, AUSTRALIA and NEW ZEALAND, were already part of the "new world" as a result of their relatively short histories and extreme distances from the heartland. Not only was the periphery noticeably smaller than the world island, it necessarily required a great deal of sea transport to function on a technological level equal to that of the world island, given a lack of sufficient natural resources for a developed economy.
Also, the industrial centers of the periphery were necessarily located in widely separated locations, making it rather easy for the world island to send its navy to destroy each one of them in turn, with little chance of a united resistance. The world island could also locate its industries in regions further inland than the periphery, thus providing a well-stocked industrial bastion. This region Mackinder termed the heartland. It was essentially comprised of UKRAINE, western Russia, and what today we call Central Asia. Most important in all of this was the fact that the heartland contained the grain reserves of Ukraine, as well as many other natural resources. It could feed and sustain itself for long periods without outside support.
Mackinder's theory outlined a move away from Europe as the pivotal center of history. Instead, it was becoming eclipsed by a new geographical pivot of history, that of the Eurasian heartland. The main advantage of this imaginary center of a world empire, enlarged by the African continent, or world island, was that it would be invulnerable to direct attack by sea power. Mackinder said that the fate of the world depended on control of the heartland. He suggested that the heartland would be controlled by Russia or a Russian-German combination, shifting the power center
from western to eastern Eurasia. However, if Japan and China were to join allegiances, then the centrifugal force in the balance of power might be transferred to Asia alone. One of the more interesting features of Mackinder's theory was his recognition that one did not have to reside in the heartland's pivotal area to control it.
The crossing of cultures and traditions both between Western Europe and Eastern Europe and Europe and Asia marked, for Mackinder, a region of potential strategic importance in determining the power centers of the future. It could be argued that Mackinder's theory was too one-sided. He concentrated on the Eurasian heartland, whereas an opposite heartland could also exist, for example, in America. This could help explain the confrontation of capitalism and communism: the opposite polar being America, which would have a periphery in Europe, South America, and CANADA.
With the collapse of communism and the weakening of Russian dominance over Eastern Europe, Mackinder's theory could be considered a little out of date. Although Russia still maintains considerable influence and indeed some power over countries thatwere formerly members of the Soviet Union, that influence has waned measurably in Eastern Europe. If the heartland still exists, it no longer dominates a protective circle of support. The battle between Western capitalism and Eastern communism is now progressing toward a combining together, possibly through the EUROPEAN UNION, keeping distinct nationalities but becoming one Europe instead of two.
It could be argued that global mentalities and attitudes are changing. World dominance, imperialism and expansion may no longer be the driving forces behind national and international development, as much as the growing importance of economic integration, global trade, and financial stability. This does not necessarily mean that Mackinder's theory is no longer applicable. It could be that the pivotal heartland has just shifted from one means of control to another, where the new region of focus in the 21st century seems to be "he who controls China's markets, controls the world."
It remains to be seen just how necessary geography and topography really are to sound explanation and analysis of our political world. A general case can be made that such considerations are increasingly less important: that technological innovations in communications and transportation are making geographical constraints less constraining, at least for the industrialized world.
Goods and services are increasingly global in character, and national borders are increasingly porous, giving enormous advantage to administratively flexible market-states but harming and undermining those states that cannot or will not adapt to globalizing dynamics. Military technology for countries at the highest level is also less constrained than ever by geography, topography, and climate. The next generation of scientific-technical advances will accelerate such processes, making the old constraints imposed by geography and topography completely obsolete.
However, while geography may not seriously constrain the United States and a few other advanced societies, it will continue to constrain most of the states of the world most of the time.


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Today the federal judge in charge of the BP Gulf class action lawsuit gave final approval to a $7.8 billion settlement between BP and a huge class of business owners and individuals who suffered economic loss due to the historic 2010 oil spill in the Gulf of Mexico.
For a copy of the full federal court decision and settlement click here.
BP PLC announced that it expects the over 100,000 claimants currently identified as members of the class will now have access to the funds and claims settlement process. It also noted that the settlement has no cap and therefor the company could end up paying more, or less, than the estimated $7.8 billion figure.
Questions remain that will be worked out and The Legal Broadcast Network will have on one of the premier mass tort attorneys and a lawyer immersed in the BP Settlement process, Attorney Frederick "Rick" Kuykendall of Fairhope, AL and associated with the law firm of Farrell and Patel, Miami, FL. We will be interviewing Attorney Kuykendall tomorrow and look to have a full video discussion of the settlement terms so as to answer key questions of crucial interest to trial lawyers and structured settlement professionals regarding the BP Settlements, such as:
- Who will be in charge of the claims process and how soon will claims be paid.
- How are claims values calculated for the BP settlement?
- How will legal fees be paid as part of the BP settlement?
- Is it too late to file a claim for loss in the BP oil spill and how can someone find a lawyer to assist them at this point in the process?
- What will the tax status of claims be and do claimants need to declare payments as taxable income on their tax returns?
- If a claimant wants to structured their BP settlement claim to defer taxes, what is the process in the claims facility to get this done?
These and other questions of crucial importance to lawyers will be covered on the show Speaking of Justice, an in depth broadcast with Rick Kuykendall, and an exclusive conversation featured only on The Legal Broadcast Network.


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west coast homes: a study of sustainability, simplicity and harmony with nature
I was wowed recently on a trip to Vancouver, B.C. with how lush and green the city and surrounding area is, and how residents seem to value this natural phenomenon and incorporate it into their lifestyles. Parks are abundant, rooftop gardens are on countless skyscrapers and downtown buildings, and vines and plants are allowed to grow up and around city infrastructure. The thing that impressed me most, though, are the homes and how they are in harmony with their stunning natural surroundings.
West coast architecture is organic and distinctive to the Pacific northwestern coasts of Canada and the U.S. It is significantly influenced by revered architect Frank Lloyd Wright, who was quoted as saying, "Study nature, love nature, stay close to nature. It will never fail you."
Hotchkiss House by Scott Edwards
One of Wright's most well-known mentees was Arthur Erickson, a Vancouver-born architect who left his stamp on Vancouver homes and city developments. Erickson said "Architecture, as I see it, is the art of composing spaces in response to existing environmental and urbanistic conditions to answer a client's needs. In this way the building becomes the resolution between its inner being and the outer conditions imposed upon it. It is never solitary but is part of its setting and thus must blend in a timeless way with its surroundings yet show its own fresh presence."
Smith House by Erickson
Erickson was obviously plugged in to the current slow home idea of building homes that will last and be relevant for many generations. His homes use wood, exposed beams, and indoor-outdoor spaces with sweeping views of the coastal surroundings. Erickson's homes, like true west coast homes, were built not on top of the land, but as a part of it, designed to fit in as a piece of a whole.
Graham house by Arthur Erickson
As you can see from this home of Erickson's, the oldest left standing in Vancouver, the simplicity of clean lines and earth-inspired design are integrated seamlessly.
The trend today toward minimalist design fits perfectly with west coast architectural style, and proves that simple and live-able design that harmonizes with our natural surroundings will always remain relevant and modern.


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Published at Monday, January 28th, 2019 - 12:51:41 PM. Bedroom. By Alisz Schmitt.
The strategies you can use are numerous. For instance, you can use a bench for end of bed completeness as a focal point, making sure it contrasts with the bed and also with other elements in the room. The opposite strategy would be to make sure the bench blends in and in that case you can find a way to coordinate it with something else in the room like the curtains, the headboard or the area rug.
The first element of these styles to consider is gold. Because wood was always a prominent feature in Baroque furniture, gilding was often applied and the ornamentation was almost always done in gold. This bedroom features several telling characteristics, such as the extravagant gold ornamentation atop the tufted headboard. While that is decidedly Baroque, the lavish bedding is more Rococo because it is made from silk.
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I've been thinking about this post for quite awhile. For the most part I created this blog to keep friends and family updated on Madeleine's progress. I initially decided to keep the emotional side of dealing with a child with cancer out of this. Today I will break that vow because this post has been in my mind for quite some time. And also, because maybe there is someone out there that will read this and be able to find some sort of comfort in the similarity of their own feelings and reactions in dealing with their child's cancer journey. I know that all experiences are different, but in talking to some of the parents of children with cancer, there are also a lot of similarities in coping with this terrible disease.
The days leading up to diagnosis:
Madeleine was diagnosed with Neuroblastoma within three days of initially presenting her symptoms. We are very lucky in this aspect because many times it takes months to diagnose Neuroblastoma as many kids present with flu-like symptoms - not something for which one would get an MRI.
We had noticed progressive weakness in her left leg for some time. I kept second guessing myself because suddenly she would move the leg and I would think that everything was okay again. Not a day passes that I don't wish I had taken action sooner than I did. I don't know if it would have made a difference to have caught it a week or even two earlier, but that thought remains.
It was a Tuesday morning that I finally called the pediatrician. The nurse I spoke with was concerned and she had me come in to see the doctor that very day. Madeleine and I met with the pediatrician (not our usual ped.) and a medical student. They asked me a bunch of questions and did all kinds of tests. They couldn't get a reflex on either leg and seemed to be becoming increasingly more concerned. The doctor and student stopped talking to me and started only speaking with each other in medical jargon. They were both very, very serious and I started to get a little panicky. I was sure that I was going to bring her in and that they would find nothing wrong whatsoever and send us home. The doctor wanted to get some labs and x-rays to rule out any infection or fractures. She was pretty sure that this was not the case due to her preliminary tests. She also brought up having an MRI...an immedietely shocking word.
After getting the x-rays and blood work done we headed back to the pediatrician's. She informed us that everything came back fine and that we would be called to schedule an MRI. She also said that she had never seen anything like this before.
I don't remember much of what we talked about for the next two days. We couldn't get an MRI until Friday of that week. Our regular pediatrician, who had been briefed on all of this, called us multiple times throughout that week.
I first heard the word "cancer" the Wednesday night before the MRI. Ryan's father, a neurologist, had been researching Madeleine's symptoms and consulting with our pediatrician and a pediatric neurologist. Ryan told me that they all thought that it could be neuroblastoma. I often wonder what it would be like to go back to a time when I didn't know what that word meant. Ryan gently explained that it was a cancerous tumor and that is the first of many times that I broke down. I quickly decided that it wasn't that. There's no way that my baby has cancer. Weirdly that became my mantra for the next couple of days. I never said it outloud, but hundreds of times throughout the day and night that was my constant refrain: My baby doesn't have cancer. I kept insisting (again, to myself) that it was just a reaction to her immunizations, that it would go away on its own. I know now of course that I was in shock and denial.
to be continued...


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Old Town Surgery, Curie Avenue, Swindon, Wiltshire, , Email; firstname.lastname@example.com, SN1 4GBTel: 01793 616057
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I was born & raised in Southport & completed my medical training at Manchester University. I qualified in 1985 & spent the next 2 years working in hospitals in the North West & Jersey. I came to Swindon in 1987 to commence my GP training at PMH. I joined Old Town Surgery as a partner in 1991, 2 weeks before i got married. I have 2 children. Alongside my full time post in General Practice I also work for specialist drug treatment services.
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Before studying medicine I completed a Psychology degree.
My hobbies include Subaqua, swimming & cycling.
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Joanna Vargas
Ritual Brush
Why Shen Loves it: Joanna Vargas's Ritual Brush is key in helping skin attain its best glow, through invigorating the lymphatic system – it's in charge of both the delivery of nutrients and carrying away waste from skin cells all over the body. Everyone needs an extra boost in their morning ritual to help stimulate the lymphatic system and circulation, enhance collagen production and exfoliate gently every day. Use this brush on dry skin before cleansing to activate and glow.
237 Grams
Shen Recommends: Use daily on dry skin before bathing. Begin at your toes, and brush using long sweeping movements towards the heart, followed by brushing from fingertips inwards. Spend extra time on areas prone to cellulite. Always brush towards the heart to stimulate circulation.
Wash bristles in warm soapy water once a week. Dry in a well ventilated area, with bristles facing down.