(Learn more: www.heart.org). Introduction. Neck or head bracing-This will usually dramatically reduce symptoms as the unstable neck is temporarily stabilized. In patients with Ehlers Danlos Syndrome, neck pain and headaches can be related to underlying cervical spine instability. Comments on the imaging on alar, transverse ligaments. An official website of the United States government. Conservative treatment of Craniocervical Instability can consist of correcting cervical misalignment, improving overall posture and training muscles that are compensating for lax ligaments. If the risk is very small, like a specific upper cervical chiropractic adjustment, then we can have low diagnostic certainty and low disability all day long. Copyright © Regenexx 2023. A few months ago I started prolotherapy treatments on my neck below my craniocervical fusion. Rather the delicate tissues of the brain and spinal cord are irritated or compressed. The test is ended when the pressure decreases >20% or when substitution occurs during the head nod. Headaches (with the sensation that your head feels too heavy). Henderson FC Sr, Francomano CA, Koby M, Tuchman K, Adcock J, Patel S. Neurosurg Rev. It happened so quickly. In that case, perform fewer reps next time or move back to the easier level or exercise! Some have raised concerns about CCI surgery in patients with ME/CFS given the lack of research on OCF in this patient population.[68]. The goal is to strengthen damaged or lax ligaments in patients with Craniocervical Instability (CCI). from lying down to sitting up). Sometimes this part of the evaluation isn’t needed because the other puzzle pieces all fit. The first line of treatment typically includes conservative therapies, such as rest, activity modification, bracing to support your spine, and physical therapy or exercises to improve spinal strength. Atlanto Chris Centeno, M.D. Cervicogenic Dizziness in an 11-Year-Old Girl: A Case Report. This means you just look at these targets while keeping your LASER point in the middle of the clock face. Physical Therapy, Volume 93, Issue 7, 1 July 2013, Pages 986–992, ... the rotation stress test for the alar ligaments in a sample of individuals with no history of cervical spine injury or instability. "[43] as it is reported to be uncommon in the healthy population. The problem? Reported here is the case of a 40-year-old male presented with neck pain, dizziness, and aural symptoms in the past 12 months. Traditional “conservative” treatments for CCI include rest, pain management, upper cervical chiropractic treatment, and bracing with a cervical collar. This final puzzle piece is whether the patient has had the correct response to treatments that often help CCI patients. The minority of patients have a … It is not covered by insurance and is still considered an \"experimental treatment\", but it has helped many significantly. It looks like this (click on the picture to the left for an Amazon link). Cervical spinal fusion is performed on patients with more severe symptoms. For example, tenderness in the upper cervical spine facet joints or issues with sensation in the upper cervical spinal nerve root territories. Thats the post-PICL rehab program for patients wanting to know how to best do CCI exercises. Many people can benefit from physical therapy, medications, and nerve blocks to alleviate headaches for a long time. Comparison of cervical alignment on sagittal radiographs in neutral position. ", "Tendon Injury and Fluoroquinolone Use: A Systematic Review", "Craniocervical spinal instability after type 1 Arnold Chiari decompression: a case report", "REVIEW OF THE 2013 CSF RESEARCH COLLOQUIUM & CONSENSUS ON CRANIOCERVICAL INSTABILITY – Bobby Jones CSF", "Computed tomography evaluation of the normal craniocervical junction craniometry in 100 asymptomatic patients", "Angular craniometry in craniocervical junction malformation", "Rheumatoid arthritis of the cervical spine: surface-coil MR imaging", "Videoed Presentation at: ASAP Chiari & Syringomyelia Conference Paolo Bolognese, MD "Complex Chiari. [53]) During surgery, titanium hardware is used to fixate the occiput, axis and atlas (i.e., C0 to C2) while rib graft, cadaver bone graft or synthetic bone is used to help the bones fuse together. cactus club spicy yogurt recipe. ... One study demonstrated success combining physical therapy, cognitive behavioral therapy, and group therapy, followed by individual home exercises and weekly guidance by physiotherapist for three months, then … [16], AAI becomes symptomatic when the displaced dens impinges on the spinal cord. For this exercise, well be using the small clock face inside the bigger one. Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility, is a structural instability of the craniocervical junction which may lead to apathological deformation of the brainstem, upper spinal cord, and cerebellum. Prolotherapy and Prolozone Therapy. In our patient above, the surgeon relied only on a C1-C2 rotational measurement on CT scan. Criminal Possession Of A Weapon 2nd Degree Jail Time, eCollection 2021. Common symptoms of Cranial Cervical Instability include a painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue. 2019 Dec;42(4):915-936. doi: 10.1007/s10143-018-01070-4. See my video below: This means that the areas that hurt are diagnosed by precisely injecting anesthetic into that area to see if that numbs out the pain or takes away other symptoms. Your doctor is puzzled as all your tests are normal. long dirty jokes; most expensive fixed blade knives; povi masima recipe; arte johnson tricycle In CCI the ligamentous connections of the craniocervical junction can be stretched, weakened or ruptured. Regenexx clinic. The worse would be low certainty that the patient has CCI and low disability. government site. What is the PICL Procedure? Instability of the C0-C1 and C1-C2 joints occur due to malformation of the Axis (C2), specifically the Dens and or laxity of the transverse ligament caused by collagen defects [2]. Prolotherapy and Prolozone Therapy are deemed as the most effective treatment options for cervical instability. We use these six main criteria: Think of this as putting together puzzle pieces that create a picture. This is version 1 of this book and while it has been read by several CCI patient advocates who made suggestions if you find things that require correction or have ideas for improvements, please send a quick email to the author at[emailprotected]! For this exercise, start at the center point and then try 11, 1, 7, 5 in the way as described above (center, number, back to center). Christopher J. Centeno, M.D. For example, this data was recently published for DMX. Conservative treatment with rest, physical therapy modalities and pain management can be attempted initially. For higher functioning patients this may only represent a week. Comments on upper cervical neck imaging for CCJ instability. eCollection 2017. A symptom of postural orthostatic tachycardia syndrome (POTS). Or there are times when three pieces are placed when it’s easy to guess the picture because it can’t be anything else. If non-invasive treatments for CCI fail to work, occipito-cervical fusion (OCF) can be considered. I got it printed for $25 at VistaPrint on a matte 36X48 poster. She seemed perplexed that a surgeon had put her on the schedule for this invasive procedure and yet she couldn’t meet our criteria for a diagnosis of CCI. Then integrate L1-Ex1 + L1-Ex2 together (so 20 reps in total). This is clinically important since, for example, physiotherapy has been found to be effective for Cervicogenic Headache (CGH) but not for migraine. The craniocervical junction (CCJ) is the most mobile portion of the spine, capable of flexion, extension, and lateral rotation .The CCJ is composed of the occiput (C0), atlas (C1), axis (C2), and associated ligaments and muscles , , .Its complex structure allows it to achieve a high degree of mobility while maintaining mechanical stability, defined by White … Dr. Centenos new book onCraniocervical Instabilityis now ready to go! It has been such a pleasure to work with the team involved in this article. Symptoms associated with AAI and OAI include: A thorough assessment of the cervical spine should be completed in order to distinguish the cause of neck pain and presenting symptoms. You may want to stay with these first two exercises for the first week or move on more quickly if this is easy. (a) At initial…, MeSH Smart Crossword Clue 4 Letters, Physical therapy is key to managing Ehlers-Danlos Syndrome, Marfan’s Syndrome, and joint hypermobility (double jointed). Motor vehicle accidents, contact sports, and forceful manipulations by chiropractors are the most common examples of trauma. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. The .gov means it’s official. Approximately one-third of all cervical spine injuries involve the craniocervical junction (CCJ). sharing sensitive information, make sure you’re on a federal HHS Vulnerability Disclosure, Help The patient reported salutary consequences to the 3-month treatment course with no neurologic sequelae. Manual traction, halo and invasive cervical traction may be used to aid in the diagnosis of CCI. A critical first step BEFORE you start any rehab program is to determine if youre ready to start at all. Similarly, if you can move through it quickly without flare-ups, then thats great. Sport and physical activity are highly beneficial for people with DS in regards to biological, psychological and social spheres. This report reviews the history, physical exam, and diagnostic imaging findings of a patient with the above symptoms. Proprioception of the wrist joint: a review of current concepts and possible implications on the rehabilitation of the wrist. The Foramen Magnum is a large hole at the base of the skull that allows the brain to join the spinal canal. Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. 2019 Dec 9;2019(11):476-478. doi: 10.1093/omcr/omz115. That’s not what I’m talking about. Craniocervical instability may give you the sensation that your head is bobbing or moving uncontrollably. While these patients of craniocervical instability often get very dangerous and invasive surgery, we have developed a non-surgical, injection-based approach that uses your own bone marrow concentrate, carefully delivered into the alar, transverse, and accessory ligaments using our one of a kind PICL (Percutaneous Implantation of the CCJ Ligaments), the trusted non-surgical craniocervical instability treatment. Finally published in full! Video 1: Technique of craniocervical reduction, stabilization, and fusion The surgical procedure involves the placement of a Mayfield head clamp and a neck brace. So this puzzle piece is a firm positive. . In this case, the patient may realize temporary relief from treating beat up upper neck joints or nerves, despite not treating the instability directly. objective outcome An outcome of a clinical trial that is independent of the judgement of opinion of the assessor/clinician, e.g. The flow of sensorimotor retraining strategy is recommended: 1. There are also two levels of knowledge for providers, one common and one rare. ... One study demonstrated success combining physical therapy, cognitive behavioral therapy, and group therapy, followed by individual home exercises and weekly guidance by physiotherapist for three months, then readmission for … Hence, did the patient hit their head forcefully or have a neck injury in a car crash? This rehab program is NOT for patients who have already had an upper neck fusion for CCI. Would you like email updates of new search results? WebCraniocervical instability is a medical condition where there is excessive movement of the vertebrae at the atlanto-occipital joint and the atlanto-axial joint, that is, between the … Occipito-axial instability (OAI) is less researched in the DS population compared to AAI. eCollection 2021. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Symptomatic improvement with traction can help determine whether a patient with abnormal measurements will benefit from craniocervical fusion surgery. Hence, the pain usually returns. The increased recognition of hypermobility syndromic disorders, of which Ehlers Danlos Syndome (EDS) is emblematic, has prompted questions and concern as to what constitutes pathological instability in this category of patient, and how best to diagnose this instability. CCI refers to instability in any part of the craniocervical junction, Cervical Medullary Syndrome is a clinical condition that occurs as a result of inflammation, deformity, or compression of the lower part of the brain. Bethesda, MD 20894, Web Policies excerpt: "Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility, is a structural instability of the craniocervical junction which may lead to a pathological deformation of the brainstem, upper spinal cord, and cerebellum. The level of disability is important in diagnosing craniocervical instability (CCI). Original Editor - Beth Potter | Catherine Stanislas | Emily Westwood | Laura Beaman, Top Contributors - Beth Potter, Cindy John-Chu, Laura Beaman, Kim Jackson and Rucha Gadgil, Down Syndrome (DS), also known as Trisomy 21, is a condition caused by the presence of an extra chromosome (chromosome 21) which results in atypical physical and cognitive development. Joint Hypermobility and Hypermobility Syndrome, Social Security Disability and Social Security Disability Insurance, Venous Sinus Stenting & Vascular Procedures, reduced gag reflux and difficulty swallowing, downward nystagmus (irregular eye movements), a heavy headache: a constant to near constant headache that can be described as feeling like the head is too heavy for the neck to support (feeling like a “bobble-head”). 2016;96(6):876–887. Other experimental treatments for CCI include prolotherapy and stem cell therapy. If non-invasive treatments for CCI fail to work, occipito-cervical fusion (OCF) can be considered. OCF is a surgery that aims at a biomechanical stabilization of the craniocervical junction. Traumatic cranio-cervical instability in childhood is rare and constitutes a challenge for the treating surgeon. Common symptoms of Cranial Cervical Instability include a painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue.CCI or neck ligament laxity treatment options depend upon the severity of the instability andclinical symptoms. One of the more common questions I get from patients who undergo the PICL procedure is what does the physical therapy or rehab program look like after the procedure. May be minor or serious. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you. 2019;2019(11):476–478. Most neurosurgeons prefer upright MRI with flexion and extension. 2014;95(9):1603–1612. [32]When identifying factors predictive of fusion failure, the singular significant factor was DS. This patient, who had a history of multiple cervical spine injuries, was examined with 2 manual therapy provocative tests: the Sharp-Purser test, which is intended to stress the transverse ligament and odontoid, and the modified lateral … We use advanced imaging and treatment options to diagnose and manage your condition. Cervicogenic Dizziness Associated With Craniocervical Instability: A Case Report . If this is difficult, then try a small pillow in the small of your back (lumbar) which will often help keep your shoulders back. These ligaments include the alar, transverse, accessory, apical dens, and others. The aim of therapy is to restore cervical stability … Indian J Otolaryngol Head Neck Surg. -, Stanton TR, Leake HB, Chalmers KJ, Moseley GL. Therefore I discussed with the patient that getting a DMX study would help add additional information to this puzzle piece. Trochanteric osteotomy is a type of hip replacement procedure that can also be done, but it is usually carried out under very specific circumstances. You could enter this type of program commonly after level 4 or 5 or later. Here are some common diagnostic blocks we use for CCI: Our patient above had only simple occipital nerve blocks, so was missing most of the injection-based diagnostic workup. Cervical spinal fusion is performed on patients with more severe symptoms. Ali FE, Al-Bustan MA, Al-Busairi WA, Al-Mulla FA, Esbaita EY. For this level, you increase your targets to 180 degrees (about 90 degrees to each side as shown). tendon a fibrous cord of tissue that connects muscle to bone. The Zebra Network ("TZN") is operating through a fiscal sponsorship with Players’ Philanthropy Fund, Inc. (Federal Tax ID: 27-6601178), a Maryland not-for-profit public benefit corporation with federal tax-exempt status from the IRS under Section 501(c)(3). supine lying on the back or with the face upward. post-exertional malaise (PEM) - A notable exacerbation of symptoms brought on by small physical or cognitive exertions. Updated: Sep 6, 2022. This week I had a telemedicine evaluation with a patient who was scheduled for a C1-C2 screw fixation surgery who didn’t meet our diagnostic criteria for a much less invasive injection-based procedure to treat craniocervical instability. [14], The complications of OCF can be serious[55] and occur in an estimated 7% to 33% of patients. The is one on the right and one on the left. payment for the information provided. What was your level of function … What was your level of function … Press J to jump to the feed. Report of three cases", "Occipital cervical stabilization using occipital condyles for cranial fixation: technical case report", "MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction", "Occult hypermobility of the craniocervical junction: a case report and review", "Nontraumatic Atlanto-occipital and Atlantoaxial Rotatory Subluxation: Case Report", "Non-Traumatic Atlanto-Occipital and Atlanto-Axial Dislocation: A Case Report", "Structural odontoid lesions in craniovertebral tuberculosis: a review of 15 cases", "Craniovertebral junction abnormalities in Down syndrome", "Craniocervical instability in the setting of os odontoideum: assessment of cause, presentation, and surgical outcomes in a series of 279 cases", "Oral Fluoroquinolones and Risk of Mitral and Aortic Regurgitation", "Spontaneous cervical artery dissection: a fluoroquinolone induced connective tissue disorder? Hence, finding a local provider who knows how to do these can be problematic. excerpt: "Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility, is a structural instability of the craniocervical junction which may lead to a pathological deformation of the brainstem, upper spinal cord, and cerebellum. WebAfter exclusion of other neurological, vascular and vestibular causes, craniocervical instability was considered as the cause of the CGD. Cremers MJ, Bol E, De Roos F, Van Gijn J. Morton RE, Khan MA, Murray-Leslie C, Elliott S. British Gymnastics. Little research on outcomes exists. Radiographic clues illustrated a subtle anterolisthesis of the occiput on the cervical spine, manifested by a dissociation of the clivo-axial angle (CXA). At the CCJ Instability Institute, helping your body heal these ligaments is what we do. Pt I – The Spinal Series, Jennifer Brea’s Amazing ME/CFS Recovering Story: the Spinal Series – Pt. Hence, please don’t sign up for any invasive surgeries until you tick all of the boxes above! From a physical therapy perspective instability usually falls into one of the following categories Chronic neck pain after whiplash, a case control study. Numerous surgical techniques, which evolved over 90 years, as well as unique … Authors Eric Chun-Pu Chu 1 , Arnold Yu-Lok Wong 2 , Linda Yin-King Lee 3 Affiliations 1 New York Chiropractic & Physiotherapy Centre, New York Medical Group, Hong Kong, China. [53] When cervical instability is present below C2, additional vertebrae may also be fused. doi: 10.1016/B978-0-444-63437-5.00026-1. Some of these conditions include craniocervical instability (CCI), Chiari malformations, tethered cord syndrome, Eagle’s syndrome, and cervical stenosis. Physical Therapy 2013 TLDR The range of craniocervical rotation during rotation stress testing of intact alar ligaments should typically be 21 degrees or less and rotation may be quantified using the method protocol outlined. Exercise programs, often self-directed, that do not take into account that EDS patients have loose joints but tight muscles are doomed to failure. OurCCI treatment is dramatically less invasive than upper neck fusion surgery with fewercomplications, less pain, and less recovery time. Physical Exam. Case report", "Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review", "Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization", "Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and Chiari malformation Type I in patients with hereditary disorders of connective tissue", "MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction - ProQuest", "Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: A case report", "Occult Hypermobility of the Craniocervical Junction: A Case Report and Review", "New Diagnostic Tools Can Contribute to Better Treatment of Patients with Chronic Whiplash Disorders", "Instrumented arthrodesis for non-traumatic craniocervical instability in very young children", "Secondary tinnitus as a symptom of instability in the upper cervical spine: Operative management", "Deformative stress associated with an abnormal clivo-axial angle: A finite element analysis", "Posterior Instrumentation for Occipitocervical Fusion", "Ehlers Danlos, complex Chiari and cranio-cervical fixation: how best should we treat patients with hypermobility? If you have questions or comments about this blog post, please email us at [email protected]. and physical therapy or exercises to improve spinal strength. So while it’s possible that she may have loose ligaments in the spine only as some sort of rare EDS variant, we’ll call this “Positive/Negative” for now. Keywords: Careers. Exercises, Physical Therapy, and Craniocervical Instability (CCI): … [5] No particular symptom is mandatory for a diagnosis of CCI and each symptom listed might have a cause other than CCI. The atlantoaxial joint is the most mobile portion … Can be caused by exercise or illness. Since physical therapy and acupuncture previously failed to provide a substantial, long-lasting outcome, the patient sought chiropractic care for her condition. - Journal of Spine, 2016. The aim of therapy is to restore cervical stability without limiting the range of motion. How do you test for subluxation? Subsequently he sought out chiropractic evaluation. This page was last edited on November 30, 2022, at 11:59. [4][26], More recently, physicians have reported an increased prevalence of CCI in patients with hereditary connective tissue disorders. If you feel that something is inaccurately displayed or more information is needed, please contact us. This involves a fusion of the head to the neck which is a major surgery that is associated with significant risks and complications, Disorders that affect and weaken the connective tissues such as tendons and ligaments. Given the propensity in these patients for spinal instability, it is not surprising that the most severe symptoms arise in the most mobile part of the spine, the cranio-cervical junction. Popular sites - Physical Therapy For Craniocervical Instability related sites: Together we are building a community, Industry-Leading physical therapy, Charleston Physical Therapy Specialists Charleston WV, Physiotherapy Associates, Baltimore Physical Therapy for Sports and Injury Rehab, Physical Therapy, Kelly Hawkins PT, Orthopedic Surgeons in Connecticut, … What is Craniocervical Instability or Cranial Cervical Instability? PICL Procedure (direct injection of the ligaments that hold the head on to tighten those ligaments and reduce instability), Larger upper cervical fusions with extensive hardware. Authors Eric ChunPu Chu 1 , Fadi Al Zoubi 2 , Jian Yang 3 Affiliations 1 New York Chiropractic and Physiotherapy Centre, 41/F Langham Place Office Tower, 8 Argyle Street, Hong Kong, China. Failed conservative treatment, including a reasonable trial of physical therapy (including isometric exercises of the neck), activity modification, pain medications, neck brace, and other modalities. For example, some pieces may be positive for CCI and some not so much. Injections-Diagnostic blocks can also be a treatment if they’re done with orthobiologics like platelet-rich plasma. These studies are useful to identify instability. See if you're a Candidate for the PICL Procedure. "Health update #3: My ME is in remission", "Concerns about craniocervical instability surgery in ME/CFS", postural orthostatic tachycardia syndrome, https://me-pedia.org/index.php?title=Craniocervical_instability&oldid=205715, Articles with unsourced statements from 2019, Articles with unsourced statements from 2021, Creative Commons Attribution-ShareAlike License, Invasive cervical traction (ICT) with fluoroscopy, Distance from the dura to the line drawn from the basion to the posterior inferior edge of the C2 vertebra, Distance from tip of basion to posterior axial line, Vertical distance between the basion and the dens, Change in BAI between flexion and extension positions of the head, Change in BDI between flexion and extension positions of the head, Change in BDI value when the head is pulled upward with traction force of typically up to 35 lbs, How far tip of the dens extends above Chamberlain's line, Syndrome of Occipitoatlantialaxial Hypermobility, Hypermobility of the Craniocervical Junction. Authors Eric Chun-Pu Chu 1 , Arnold Yu-Lok Wong 2 , Linda Yin-King Lee 3 Affiliations 1 New York Chiropractic & Physiotherapy Centre, New York Medical Group, Hong Kong, China. After exclusion of other neurological, vascular and vestibular causes, craniocervical instability was considered as the cause of the CGD. Imaging. Y/N, Can just random light tasks like reaching for something or typing throw your upper neck Out or cause severe symptoms? Fraser C. Henderson Sr. M.D. We need to careful here, as many of these same symptoms are also caused by other conditions. Patient-reported outcomes like questionnaires are not objectives. *DISCLAIMER: Like all medical procedures, Regenexx® Procedures have a success and failure rate. Again, how many exercises from which levels you are able to do here depends on how much you can tolerate. What I mean by that, is that these nerves can get pinched in common places or uncommon places. Conservative treatment of Craniocervical Instability can consist of correcting cervical misalignment, improving overall posture and training muscles that are compensating for lax ligaments. van Ettekoven H, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Some physical therapists who left reviews said it worked fine. Participants attributed this to other EDS comorbidities such as POTS, Mast Cell Activation Syndrome, and additional spinal problems. Craniocervical instability associated with rheumatoid arthritis: a case report and brief review AME Case Rep. 2021 Apr 25;5:12. doi: 10.21037/acr-20-131. Handb Clin Neurol. distance walked in 6 minutes. The nice part about uploading the PDF online and picking up the print is that you can save on the $9 shipping fee that Vistaprint charged. She has a low to moderate diagnostic certainty, moderate levels of disability, and is already scheduled for a “Highest Risk” procedure. You put that black strap device on your head with the LASER pointing forward. Chiropractic Management of Neck Pain Complicated by Symptomatic Vertebral Artery Stenosis and Dizziness. recent pottstown obituaries, cebuano happy birthday bisaya greetings, russian timour iii, khujo goodie first 48, mitch mcconnell daughters photos, garth fisher net worth, millville police scanner, just busted magazine dawsonville, georgia, booze crossword clue 7 letters, connect dots without crossing lines game, borax for chipmunks, concord ohio obituaries, eso how to get 70k dps, new york times higher education reporter, warren spahn fastball speed.
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