Muscular-Dystrophy:

[Information from IBIS Database]Definition: Muscular dystrophy is a group of inherited diseases characterized by progressive weakness and degeneration of muscle fibers, without evidence of neural degeneration.

Signs and symptoms:
Duchenne's ( pseudohypertrophic) is most common type; presents in boys 3-7 years old as proximal muscle weakness causing waddling gait, toe walking, lordosis, frequent falls, and difficulty climbing stairs and standing; pelvic girdle is affected first followed by the shoulder girdle.

Lab findings:
• serum CK levels markedly elevated to 50 times normal in 50% of patients
• serum CK increased in 75% of female carriers
• biopsy shows muscular atrophy


Progression is steady and patients are confined to a wheelchair by age 12; flexion contractures and scoliosis are common; death usually results in the teens or twenties, often from infection.


• Duchenne's: pseudohypertrophic
• limb girdle muscular dystrophy
• facioscapulohumeral muscular dystrophy
• polymyositis (dx via muscle biopsy)

• alternate hot and cold compresses to spine (hot 10-15 min., cold 1-2 min.)

therapeutic foods:
• increase foods rich in Calcium, Phosphorus, Manganese, Sulfur, Iodine, tryptophan (Jensen, p. 63)
• egg yolk, kale, celery, fish, raw goat's milk, veal joint broth, cod roe, rice polishings, brewer's yeast, nutritional yeast (Jensen, p. 63)

fresh juices:
• celery, carrot, prune (Jensen, p. 63)
• prune and rice polishings (Jensen, p. 63)
• raw goat's milk and 1 tsp. sesame, sunflower or almond butter, 1 tsp. honey and sliver of avocado (Jensen, p. 63)
• black cherry and egg yolk (Jensen, p. 63)

• Vitamin E 300 I.U. q.d. (Rabinovitch, pp. 95-100)
• Selenium 200-1200 mcg
• phosphatidyl choline 20 g q.d. (Milhorat, 1945)
• glutamic acid 10-20 g q.d.
• glycine 5-10 mg q.d.
• lipase, pancreatin (Bastyr)

Herbs:
• Strophanthus hispidus: muscle weakness, muscle atony in prolonged diseases (Sherman)

• Rehmannia Six F. (Liu Wei Di Huang Wan) (available as patent): For the "Five Delays" in development (Hsu, 1980, p. 245; Yeung, p. 152; Bensky and Barolet, p. 263; patent: Zhu, p. 288)
• Jian Bu Hu Qian Wan (Chen Pu Hu Chien Wen) (patent): Kidney Yin Xu (Deficiency) with Empty Fire Blazing: limbs without strength. (Naeser, p. 289)
• Vitality C. (Zhen Wu Tang): Kidney and Spleen Yang Xu (Deficiency)
(Hsu, 1980, p. 278; Yeung, p. 287; Bensky and Barolet, p. 197)
• Ginseng and Tang Kuei C.: Xue Xu (Blood Deficiency) with Spleen Qi Xu (Deficiency)
(Hsu, 1980, p. 241; Dharmananda, 1986, p. 107)

after assessing the person and palpating, consider these patterns:
Kidney Yin Xu (Deficiency) with Empty Fire Blazing; Kidney and Spleen Yang Xu (Deficiency); Xue Xu (Blood Deficiency) with Spleen Qi Xu (Deficiency); dysfunction of the Dai Mai (Girdle Vessel); dysfunction of the Yin Qiao Mai (Yin Motility Vessel) and/or the Yang Qiao Mai (Yang Motility Vessel)

» palpate and consider:
• Moxa may be very beneficial with Yang Xu (Deficiency), but must be used sparingly with young people and almost never with Yin Xu (Deficiency), esp. if there are any signs of Empty Fire. Overheating therapies misapplied tend to damage the Yin in the young and vibrant maybe even more easily than in the old and depleted.
• "According to the Trung Y Hoc (Study of Chinese Medicine, Hanoi, 1961), if trouble of Heat persists in spite of the treatment, it is necessary to temporarily stop the treatments. On the contrary, when the Perverse Heat has been completely dispersed, one must always tonify the emptiness (by needles or moxibustion)." (McWilliams, et al, Lesson 31, p. 154)

» note: see also "paralysis"

» points:
• GV-20 (+ and/or &Mac198;): adjusts Qi of the Du Mai (Governing Vessel); regulates and tonifies the Qi (&Mac198;); elevates the Clear Qi; warms the Yang (&Mac198;); spreads Liver Qi; causes Yang to ascend (&Mac198;); Sea of Marrow point; Jiao Hui Intersecting point of the six Yang channels and the Du Mai (Governing Vessel)
• GV-16 (+): calms the Shen and quiets the Soul; benefits and clears the Brain; stimulates the pituitary and central nervous system (Finkelstein, p. 80); facilitates the joints; treats "diseases of the feet and legs " (Ellis, et al, 1988, p. 380); Window of the Sky point; Sea of Marrow point
• GB-20 (+ and non-scarring d. &Mac198;): harmonizes Qi and Xue (Blood); dissipates Internal Wind; frees the channels and invigorates the collateral vessels, esp. in the neck and shoulder area
• Bl-38 (+): regulates the Shen (hence called the "Happy point"); strengthens Xu (Deficiency) conditions; treats all chronic disease; clears Empty Heat; supplements the Lung and fortifies the Spleen; strengthens the Xue (Blood); stimulates hematopoesis; tonifies the Kidney and warms the Yang; restores Yuan (Original) Qi; Pericardium psychospiritual associated point
• Bl-17 (+): tonifies the Qi; nourishes and invigorates the Xue (Blood) (esp. with &Mac198;); enriches Yin; generates Fluids; strengthens Xu (Deficient) conditions and increases stamina; strengthens upper back (- then +) (Finkelstein, p. 40); Diaphragm Shu Associated point; Hui Reunion and Master point of the Xue (Blood)
• Bl-18 (+): pacifies the Shen; stimulates the Brain; tonifies the Liver; moves Stagnant Qi; strengthens Xu (Deficiency) conditions; nourishes and regulates the Xue (Blood); nourishes Liver Yin; Liver Shu Associated point
• Bl-19 (+): tonifies the Gall Bladder; regulates the sinews and tendons; Gall Bladder Shu Associated point
• Bl-20 (+ and/or &Mac198;): regulates Spleen Qi; tonifies the Spleen; benefits the Ying (Constructive) Qi; enhances Spleen Yang to mobilize Stagnant Qi; tonifies and nourishes the Xue (Blood); provides strength to the extremities; Spleen Shu Associated point
• Bl-23 (+ and/or &Mac198;): strengthens Qi Hai and regulates Kidney Qi; tonifies the Kidney and strengthens Yang; nourishes Yin, Xue (Blood) and Kidney Jing (Essence); strengthens the lower back; Kidney Shu Associated point
• Bl-24 (+): regulates the flow of Qi and Xue (Blood); strengthens the lower back and knees
• Bl-25 (+): regulates the Qi of the Fu (Yang organs); benefits the lower back and knees; Large Intestine Shu Associated point
• Bl-30 through Bl-34 (+): consolidate Jing (Essence); treat weakness of the lower limbs
• Bl-35 (+): treats lack of Yang Qi; strengthens the lower back and legs
• Bl-54 (+ and non-scarring d. &Mac198;): strengthens waist; regulates the sinews and tendons; benefits the lower back, hips, legs and knees; Bladder He Sea Uniting and Earth point; command point of the back
• Bl-57 (+): strengthens the lower back and legs; relaxes the sinews and muscles; disperses Qi in the Bladder channel, according to Mingtang (Finkelstein, p. 49)
• GV-4 (+ and/or &Mac198;): strengthens the Kidney; benefits and replenishes the Kidney Yang; nourishes the Yuan (Original) Qi; relieves mental and physical exhaustion; strengthens the back, esp. benefits the lumbar vertebrae; reinforces and astringes the Jing (Essence); frees the channels and invigorates the collateral vessels; "Gate of Life Fire"
• GB-30 (+): invigorates the Kidney; strengthens the lower back; regulates hip joint; strengthens thigh; facilitates movement of leg ... in children (Finkelstein, p. 68); benefits the knee; treats paralysis and atony of the lower extremities; frees the channels and removes Obstructions; regulates the muscles and tendons
• LI-15 (+): harmonizes the flow of Qi and Xue (Blood); frees the channels and invigorates the collateral vessels; facilitates the joints; Independent Associated point of the shoulder (Mann, p. 9); "Shoulder Joint"
• LI-11 (+): regulates and harmonizes Qi and Ying; benefits sinews, tendons and joints; frees the channels; Large Intestine Upper He Sea Uniting, Earth and Tonification point
• LI-10 (+ and non-scarring d. &Mac198;): promotes the circulation of Qi and Xue (Blood); tonifies Qi and Xue (Blood) (Maciocia, p. 378); benefits Qi of arms and shoulders; removes Obstruction from and invigorates the channels; enhances action of the immune bodies (Finkelstein, p. 8); tonifies Yang Ming (Stomach and Large Intestine) and the internal duct of the Triple Warmer (Finkelstein, p. 8)
• LI-4 (+ and non-scarring d. &Mac198;): regulates Qi and Xue (Blood); stimulates the immune system; tonifies Lung Qi; regulates sinews and tendons; frees the channels and invigorates the collateral vessels; Large Intestine Yuan Source and Entry point
• TW-5 (+ and non-scarring d. &Mac198;): clears Obstruction from the Triple Warmer channel; opens and moves the Yang Wei Mai (Yang Linking Vessel) and regulates the Dai Mai (Girdle Vessel); tonifies Wei (Protective) Qi; facilitates the circulation of Qi in the channels and invigorates the collateral vessels; strengthens and relaxes the sinews and tendons; Triple Warmer Luo Connecting point; Master point of the Yang Wei Mai (Yang Linking Vessel); Couple point of the Dai Mai (Girdle Vessel)
• CV-6 (+ and/or &Mac198;): strengthens and moves the Qi, esp. in the Lower Warmer; influences the pituitary, thyroid and adrenals (Worsley, 1975, p. B-20); regulates Qi of Chong Mai (Penetrating Vessel) and Ren Mai (Conception Vessel); warms and strengthens the Lower and Middle Warmers (&Mac198;); tonifies the Kidney; regulates and tonifies Yuan (Original) Qi; nourishes and invigorates Kidney Yang; warms Ming Men (Life Gate Fire) (esp. with &Mac198;); reinforces the Jing (Essence); regulates Water Pathways and dispels Dampness; warms feet and hands; Dan Tien (Elixir of Long Life), with CV-5
• CV-4 (+ and/or &Mac198;): pacifies the Shen; grounds the Shen when there is Empty-Heat (Maciocia, p. 207); regulates the Qi and benefits Yuan (Original) Qi; nourishes Xue (Blood) and Yin; regulates and reinforces the Qi of the Chong Mai (Penetrating Vessel) and Ren Mai (Conception Vessel); nourishes and stabilizes the Kidney; warms the Kidney Yang (&Mac198;); Small Intestine Mu Alarm point
• GB-26 (=): regulates the Dai Mai (Girdle Vessel), hence the waist and pelvic girdle; promotes Kidney Qi circulation; clears and invigorates the channels; Entry point of Dai Mai (Girdle Vessel); special point for paralysis
• GB-31 (+): detoxifies the Liver and extinguishes Internal Wind; tonifies waist, strengthens thighs, and tonifies knees; relaxes and strengthens sinews and tendons
• GB-34 (+ and non-scarring d. &Mac198;): benefits Liver and Gall Bladder; extinguishes Liver Wind; tonifies the Spleen; clears and cools Dampness and Heat; strengthens and relaxes sinews and tendons; benefits joints, esp. knees and hips; invigorates the collateral vessels; Gall Bladder He Sea Uniting and Earth point; Hui Reunion point of Jin (sinews and tendons)
• GB-35 (+): pacifies the Shen; regulates the Gall Bladder; disperses Liver Fire; invigorates the Xue (Blood); soothes the sinews and tendons; relieves pain; treats weakness and atony of the lower extremities, esp. calf muscles; Xi Cleft Accumulation point of the Yang Wei Mai (Yang Linking Vessel)
• GB-39 (+): pacifies the Liver; extinguishes Liver Wind; tonifies the Bone Marrow; clears Heat and communicates the superficial with the internal of the three Foot Yang channels; relaxes the muscles and sinews; treats weakness and atony of the lower extremities; expels Wind-Damp and otherwise frees the channels and connecting vessels; Hui Reunion point of the Marrow; Jiao Hui Intersecting point of the three primary Yang channels of leg; Group Luo point of the three Lower Yang
• St-36 (+ and non-scarring d. &Mac198;): calms the Shen; regulates and strengthens Qi and Xue (Blood); strengthens weak and deficient conditions; strengthens all striated muscle; regulates and replenishes the Middle Warmer; regulates Ying (Constructive) Qi; spreads Liver Qi and tonifies Kidney Yin; nourishes Kidney, Liver and Spleen; frees the channels and invigorates the collateral vessels; Stomach He Sea Lower Uniting, Earth and Horary point; Sea of Nourishment point
• Sp-9 (+): regulates and tonifies Spleen (especially Yang); warms and moves the Middle Warmer; treats weakness of the legs; Spleen He Sea Uniting and Water point
• Sp-6 (+): pacifies the Shen; nourishes Yin, esp. of the Spleen, Liver and Kidney; influences the pituitary and adrenals (Worsley, 1985, p. B-20); clears Fire due to Xu (Deficiency); strengthens the Spleen and tonifies the Qi; regulates, clears, nourishes and moves the Xue (Blood); aids transportation and transformation to improve digestion and nourishment; frees Qi Stagnation and spreads the Liver Qi; warms the Middle and Lower Warmers; tonifies the Kidney; Jiao Hui Intersecting point of the three Foot Yin channels
• Sp-4 (+): pacifies the Shen; moves and strengthens the Spleen and Middle Warmer; harmonizes the Chong Mai (Penetrating Vessel) and circulation of Qi in the Middle Warmer; invigorates the Xue (Blood) and regulates the Sea of Xue (Blood); regulates the Yin Wei Mai (Yin Linking Vessel); tonifies Yuan (Original) Qi; Spleen Luo Connecting point; Master point of Chong Mai (Penetrating Vessel); Couple point of the Yin Wei Mai (Yin Linking Vessel)
• Sp-3 (+): regulates and strengthens the Spleen (especially Qi and Yang); harmonizes the Middle Warmer; Spleen Yuan Source, Earth and Horary point
• Kd-9 (+): pacifies the Shen; strengthens Yuan (Original) Qi; regulates Yin Wei Mai (Yin Linking Vessel); warms the Kidney; tonifies Kidney Qi, Kidney Yin and Jing (Essence); eliminates hereditary dysfunction (primarily used in utero, but still possibly appropriate given young children with chronic disease); treats weakness in the legs; Entry and Xi Cleft Accumulation point of the Yin Wei Mai (Yin Linking Vessel)
• Kd-7 (+ and non-scarring d. &Mac198;): strengthens Spleen and nourishes Yin; tonifies Yuan (Original) Qi; strengthens and enriches the Kidney; stimulates adrenals, thyroid and testes; strengthens the low back; Kidney Metal and Tonification point
• Kd-4 (+): nourishes the Shen and Yin; regulates the Kidney; reinforces the Liver and Kidney, the latter through longitudinal Luo vessels; facilitates the flow of Qi and Xue (Blood); supplements the Jing (Essence); Kidney Luo Connecting point
• Kd-3 (+ and/or &Mac198;): tonifies the Kidney, Yuan (Original) Qi, Xue (Blood) and Jing (Essence); nourishes and enriches Kidney Yin, supplies Liver Yin, and tonifies Yin of the entire body; pacifies Xu (Deficiency) Fire; strengthens the Brain; tonifies Kidney Yang and Ming Men Fire (&Mac198;); regulates the Chong Mai (Penetrating Vessel) and Ren Mai (Conception Vessel); strengthens lower back, waist and knees; Kidney Yuan Source and Earth point
• Lv-3 (+ and non-scarring d. &Mac198;): pacifies the Shen; regulates the Liver and Gall Bladder; promotes smooth flow of Qi and Xue (Blood); regulates the Qi and spreads Liver Qi Stagnation; calms and extinguishes Liver Wind; tonifies Liver Xue (Blood); opens the channels and regulates muscle contractility; Liver Yuan Source and Earth point

• ear: sympathetic, liver, brain stem, corresponding areas (Eisen)

» illustrative combinations:
• Bl-25, Bl-30, GV-4, thread St-38 to Bl-57, thread GB-34 to Sp-9 for progressive muscular dystrophy (Shanghai, p. 212)
• GB-20, Bl-54, LI-10, LI-4, TW-5, GB-34, St-36, Kd-7 and Lv-3 (all: + and non-scarring d. &Mac198;) for muscular dystrophy (Eisen)
• GV-14, Bl-11 and GB-21 for progressive muscular atrophy of the upper back (McWilliams, et al, Lesson 31, p. 155)
• LI-15, SI-9, SI-10 and SI-11 for progressive muscular atrophy of the shoulder region (McWilliams, et al, Lesson 31, p. 155)
• LI-15, LI-11 and LI-4 for progressive muscular atrophy of the upper limbs; consider also TW-15, TW-10, LI-10, TW-5 and SI-3 (McWilliams, et al, Lesson 31, p. 154)
• LI-11, LI-10, PC-3, TW-4, PC-7, LI-4, TW-5 and TW-3 with needle and TW-8 with moxa only for progressive muscular atrophy of the upper limbs (McWilliams, et al, Lesson 31, p. 155)
• GB-30, GB-34 and GB-39 for progressive muscular atrophy of the lower limbs; consider also GB-31 and St-36 (McWilliams, et al, Lesson 31, p. 154)
• GB-30, GB-31, St-36 and GB-34 for progressive muscular atrophy of the lower limbs (McWilliams, et al, Lesson 31, p. 155)
• GB-34 (repeated &Mac198;) with St-36 (+) for progressive muscular atrophy of the lower limbs (McWilliams, et al, Lesson 31, p. 155)
• GV-3 for progressive muscular atrophy of the loins (McWilliams, et al, Lesson 31, p. 155)
• GB-39, then St-38 for difficulty in moving the legs (Ellis, et al, 1988, p. 134)
• Lv-4 and Lv-3 for difficulty in walking (Shanghai, p. 292)
• GB-39, Kd-3, Bl-60 and St-41 for progressive muscular atrophy of the ankle (McWilliams, et al, Lesson 31, p. 155)
• Kd-6 and Lu-7: open and regulate the Yin Qiao Mai (Yin Motility Vessel) which regulates muscular activity
• Bl-62 and SI-3: open and regulate the Yang Qiao Mai (Yang Motility Vessel) which regulates muscular activity
• GV-16 and GV-20: treat brain disorders (Finkelstein, p. 81)


• Arsenicum album: paralysis comes on slowly, preceded by shaking, pains and contractions, esp. in the legs (lesion of the lower part of spinal cord); then pains
(burning, < cold, > warmth), cramps, shaking, contractions, and atrophy increase; often with edema of ankles
• Carboneum sulphuratum: very weak, emaciated; chilly, irritable, dazed, vertigo,
+ Rhomberg test; motility problems; extremely sharp pains come and go suddenly; cutaneous hypoesthesia of lower limbs
• Causticum: weakness; localized and progressive paralysis; generalized paresis; stiffness and contractions
• Lathyrus sativus: spasmodic paresis or paralysis of lower limbs with stiffness, exaggeration of reflexes; tendency to muscular atrophy; no pain except a few cramps; < cold
• Mercurius solubilis: weakness of limbs, bone pains in limbs, < at night; sensitivity to cold; oily perspiration; trembling extremities, especially hands; cold clammy sweat on legs at night; dropsical swelling of feet and legs
• Oleum jecoris aselli: young child very emaciated
• Phosphorus: general loss of shape of the skeleton; paretic weakness of the back and legs; great weakness of the spine and limbs; increasing; loss of reflex and flabby paralysis
• Physostigma venenosum: great weakness and muscular impotence with locomotor troubles and tendency to paralysis; difficult contraction of muscles; motor incoordination; progressive muscular atrophy; numerous spasms (cramps in hands, shaking, sudden jolt of limbs on falling asleep)


musculoskeletal:
• Sousa's marches
• The Anvil Chorus
• William Tell Overture
• Brahm's Hungarian Dances
• By the Waters of the Minnetonka
(Heline, p. 18)

• aloe vera
• blackberry
• California poppy
• dandelion
(Gurudas, pp. 210, 214, 212)

• olive (Weeks, p. 127)

• Digitron: 88.5-6

• green (promotes tissue and muscle restoration; is antimicrobial and acts as a disinfectant and antiseptic) on whole body
• blue (promotes relaxation; lowers high temperatures and reduces inflamed tissue) on front if fever
• motor nervous system schedule (refer below) on whole body
• scarlet (a general stimulant; strengthens arteries) on whole body

the protocol for the motor nervous system schedule is:
• lemon (helps to dissolve blood clots; acts as a chronic alterative) and yellow (acts on the motor nerves, thereby helping to energize muscles; acts on the lymphatic system as it is a mild tissue stimulant) for 2 weeks, then:
• lemon and orange (acts as a decongestant) for 4 week
• this is repeated for as long as is necessary
(Dinshah, 1985, p. 105)


• Extreme fear; frantic desire to control everything and everyone; a deep need to feel safe; loss of faith and trust. (Hay, 1984, p. 176)

Chinese psychophysiology:
• Kidney &Mac197; Shen stores Jing (Essence) and governs birth, growth, reproduction, development, and aging; houses the Zhi (Will); expresses ambition and focus; produces the Marrow which generates the spinal cord, "fills up" the brain, and possibly manifests through the immune system; nourishes the brain to sustain concentration, clear thinking, and memory; carries the constitutional endowment from the parents and thus is especially relevant in congenital conditions; and displays the effects of overwork, chronic degenerative processes, and extreme stress.
» Healthy expressions are gentleness, groundedness, and endurance.
» Kidney Xu (Deficiency) signs include indecisiveness; confused speech; dreams of trees submerged under water; cold feet and legs; abundant sweating (Seem, p. 28); fearfulness; apathy; chronic fatigue; discouragement; scatteredness; lack of will; negativity; impatience; difficult inhalation; low sex drive; lumbago; sciatica; and musculoskeletal irritation and inflammation, especially when worse from touch. As always, chronic Yin Xu (Deficiency) predisposes to Empty Heat and/or acute inflammation.
» Intense or prolonged fear depletes the Kidney. Overwork, parenting, simple aging, and a sedentary or excessively indulgent lifestyle all contribute significantly to Kidney Xu (Deficiency).
» Mental signs of Kidney channel disorders include anxiety, fear in the pit of the stomach; sadness; mental and physical fatigue; antisocial tendencies; and laziness. (Seem, p. 28)

• Liver &Mac197; Gan is the home of the Hun (Ethereal Soul); it relates to decisiveness, control, and the principle of emergence; stores and cleanses the Xue (Blood); maintains smooth flow of Qi and Xue (Blood); controls the muscles, ligaments, and tendons, especially the contractility of the muscles; expresses itself in the nervous system; and reflects emotional harmony and movement.
» Healthy expressions are kindness, spontaneity, and ease of movement.
» Liver Xu (Deficiency) signs include impotence; frigidity; pain in thighs, pelvic region, and throat; ready tendency to "the blahs" (Seem, p. 28); timidity; depression; irritability; vertigo; pruritus; dry eyes, skin, and/or tendons; asthma; aching at the waist; hernia; and difficulty raising head up and down.

• Spleen &Mac197; Pi governs digestion and manifests in the muscle tissues; transforms food into Qi and Xue (Blood); governs the Xue (Blood); resolves Dampness and Phlegm; and relates to the ability to assimilate, stabilize, and feel centered and balanced.
» Healthy expressions are fairness, openness, deep thinking, and reminiscence.
» Spleen Xu (Deficiency) signs include slightness (deficient "form"); abundant elimination; morning fatigue; cold, wet feet (Seem, p. 28); abdomen taut and distended like a drum; craving for sweets; flatulence; nausea; mild edema; memory failure; heavy feeling in legs; pale lips; loose stools; and muscular weakness.
» The excessive use of the mind in thinking, studying, concentrating, and memorizing over a long period of time tends to weaken the Spleen. This also includes excessive pensiveness and constant brooding. (Maciocia, p. 241) Likewise, inadequate physical exercise and excess consumption of sweet and/or Cold foods will also deplete the Spleen. Environmentally, the Spleen is highly susceptible to attack from external Dampness and Cold.


affirmation:
• It is safe for me to be alive. It is safe to be me. I am good enough as I am. I trust myself. (Hay, 1984, p. 176)

process paradigm: (experientially oriented)
• What is the symptom preventing me from doing? What is the symptom making me do? (see process interview: psycho/neurological system)

related materia medica listings:
the shadow and physical symptoms
body reveals: the spirit
converting a symptom to a signal
affirmations: guidelines and precautions
process paradigm

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