Additional Material Testable on Final Flashcards
Urinary System (Structures)
-Kidney’s (2)
-Ureters (2)
-Bladder
-Urethra
Urinary System (Functions)
- Regulation of volume & composition of body fluids
- Regulation of electrolyte/ion balance
- Regulation of acid-base (pH) balance
- Hormone production & secretion
- Waste excretion
- Regulation of blood glucose levels
Regulation of the volume & composition of body fluids (Maintenance of normal body fluid levels is important for)
Maintenance of normal body fluid levels is important for:
-Maintaining normal cell volume
-Normal function of cardiovascular system
Urinary system does this by:
-Regulating excretion of water & NaCl
-Enzyme secretion (renin) which results in water retention
*Retaining water INCREASES blood pressure
*Elimination water DECREASES blood pressure
Maintenance of normal body fluid levels is important for?
-Maintaining normal cell volume
-Normal function of cardiovascular system
Urinary system maintains body fluid levels by?
-Regulating excretion of water & NaCl
-Enzyme secretion (renin) which results in water retention
Retaining water _______________ blood pressure
INCREASES
Elimination water______________ blood pressure
DECREASES
Regulation of Electrolyte/Ion Balance (Urinary System regulates several important ions including (but not limited to)
Urinary System regulates several important ions including (but not limited to):
-Hydrogen (H+)
-Sodium (Na+)
-Potassium (K+)
-Calcium (Cl2+)
-Chloride (Cl-)
-Bicarbonate (HCO3-)
-Phosphate (PO43-)
*If intake exceeds excretion, amount of that electrolyte in body increases
*If excretion exceeds Intake, amount of that electrolyte in body decreases
If intake exceeds excretion, amount of that electrolyte in body ______________.
Increases
If excretion exceeds Intake, amount of that electrolyte in body _______________.
Decreases
Regulation of Acid-Base (PH) Balance
-Many functions of body are very sensitive to pH therefore it must be maintained within strict homeostatic limits
-Kidneys play key role in regulating acid-base balance
-Kidneys regulate it by excreting hydrogen ions (H+) & reabsorbing bicarbonate
Hormone Production & Secretion (Kidney’s Secrete)
Kidney’s Secrete:
-Erythropoietin
-Calcitriol
-Renin
Hormone Production & Secretion *Erythropoietin
Stimulates red blood cell production
Hormone Production & Secretion *Calcitriol
Active form of vitamin D
Hormone Production & Secretion *Renin
enzyme that activates renin-angiotensin-aldosterone system (helps in regulation of blood pressure & NA+ & K+ balance)
Waste Excretion
-Kidney excrete metabolic by-products that are not needed by the body
-Formation and elimination of urine
which contains:
-Ammonia & urea
-Bilirubin
-Uric acid
-Creatinine
-Medications, toxins
Ammonia & Urea
Waste products from protein metabolism
Bilirubin
Waste product from breakdown of hemoglobin
Uric Acid
Waste product from breakdown of nucleic acids
Creatine
Waste product from skeletal muscle
Regulation of blood glucose levels
-With hypoglycaemia, kidneys can produce & release glucose into blood stream
Kidneys
-Retroperitoneal
-Located between T12 & L3, partially protected by ribs 11 & 12
-Renal Cortex: Superficial Layer
-Renal Medulla: Inner Portion
-Nephron: Functional unit of the kidney
Has 3 parts:
-Proximal Convoluted Tubule (PCT)
-Loop of Henle (nephron loop)
-Distal Convoluted Tubule (DCT)
-Renal artery & vein
-Kidneys get 20-25% of resting CO
Renal Cortex
Superficial Layer of Kidney
Renal Medulla
Inner Portion of Kidney
Nephron
Functional unit of kidney
Nephron has 3 parts
-Proximal Convoluted Tubule (PCT)
-Loop of Henle (nephron loop)
-Distal Convoluted Tubule (DCT)
Urine production & Flow (Blood flow)
-Blood enters kidney (renal artery) & branches into smaller and smaller vessels
-Afferent arteriole leads into glomerulus
-Glomerulus: A tangled ball-like network of capillaries (pl. glomeruli)
-At level of glomerulus, water & solutes in blood plasma are filtered through capillary walls, into glomerular (Bowman’s) capsule space & into renal tubule
-Blood flows out of glomerulus into efferent arteriole
-Efferent arteriole leads to another capillary network - peritubular capillaries
-Peritubular capillaries merge to ultimately form renal vein which leaves kidney
Glomerulus
Tangled ball-like network of capillaries (pl. glomeruli)
Urine production & Flow (the Glomerulus)
-At level of glomerulus, water & solutes in blood plasma are filtered through the capillary walls, into glomerular (Bowman’s) capsule space & into renal tubule
-Fluid enters capsular space is called glomerular filtrate
As filtered fluid moves along the renal tubule & connecting duct:
-Most of the water & usful solutes are reabsorbed & returned to blood in peritubular capillaries
-Wastes are drawm from peritubular capillaries & are secreted into fluid for removal from body
-Urine: fluid produced by kidneys that contains wastes & excess materials
Urine
fluid produced by kidneys that contains wastes & excess materials
Glomerular is also known as?
Bowmans
Glomerulr Filtration Rate (GFR)
-Amount of filtrate formed per min
-GFR is indicator of kidney function
-GFR is fairly constant under normal conditions
-Increased GFR = Increased urine production
-Decreased GFR = Decreased urine production
Fluid enters the capsular space is called ____________
Glomerular Filtrate
Increased GFR = _________________
Increased urine production
Decreased GFR = _________________
Decreased urine production
Regulation of GFR
In general, body will regulate GFR by:
-Adjusting blood flow into and out of glomerulus
-Altering capillary surface area available for filtration
There are 3 ways the body controls GFR
- Renal auto-regulation
- Neural regulation
- Hormonal regulation
Renal Auto-Regulation of GFR
-Myogenic Mechanism
-Tubuloglomerular Feedback
Myogenic Mechanism
-Increase in BP Increases renal blood flow which increases GFR
-Stretches walls of afferent arterioles
-Stretching triggers contraction of smooth muscles in walls of afferent arterioles
-Vasoconstiction reduces blood flow & reduces GFR to previous level
-Opposite happens with decrease in BP
Tubuloglomerular Feedback
-Increase in BP increases renal blood flow which increases GFR
-Also increases Na+, Cl-, & water in tubular fluid
-The increased Na+, Cl-, & water in tubular fluid triggers vasoconstriction of afferent arteriole
-Vasoconstriction reduces blood flow and decreases GFR to previous level
-Opposite happens with decrease in BP
Neural Regulation of GFR
-Kidney gets SyNS innervation
-SyNS activation causes vasoconstriction (both afferent & efferent)
-With increasing SyNS activation, vasoconstriction of afferent arteriole is greater which decreases GFR
-This reduces GFR & helps redirect blood flow to other tissues
Hormonal Regulation of GFR
Angiotensin II
-Strong vasoconstrictor (both afferent and efferent)
-Reduces GFR
Atrial Natriuretic peptide (ANP)
-Released by heart in response to atrial stretching (i.e. increased blood volume)
-Increases GFR
Angiotensin II
-Strong vasoconstrictor (both afferent and efferent)
-Reduces GFR
Atrial Natriuretic peptide (ANP)
-Released by heart in response to atrial stretching (i.e. increased blood volume)
-Increases GFR
Hormonal Regulation of Re-Absorbtion & Secretion
-Re-absorbtion & secretion occur once filtrate (fluid that comes out of glomerulus) is formed
-Normally, most water & solutes return to the body & many wastes (H+, ammonium, medications) are secreted onto tubule for elimination
5 hormones affect the re-absorbtion & secretion of water & ions by the renal tubules
- Angiotensin II
- Aldosterone
- ANP
- ADH
- PTH
Renin-Angiotensin-Aldosterone System
-Decreased BP -> Kidneys secrete renin (an enzyme)
-Renin converts angiotensinogen (made by liver) into angiotensin I
-Angiotensin I is converted to angiotensin II at lungs by angiotensin-converting enzyme (ACE)
Angiotensin II:
-Decrease GFR (afferent arteriole vasoconstriction
-Re-absorbtion of Na+ & Cl- ions & water
-Stimulates release of aldosterone
Aldosterone
Increase re-absorbtion of Na+, Cl-, & water
ANP
Increases excretion of sodium and water
ADH
Increases water reabsorption
Parathyroid Hormone
Increases re-absorbtion of calcium
Ureters, Bladder, & Urethra
-Collecting ducts (which receive urine from several nephrons), collect & form larger & larger pathways to level of the ureter (1 from each kidney)
-Peristaltic contractions in ureter move urine to bladder
-Bladder is a hollow muscular organ that sits posterior to pubic symphysis, anterior to rectum, & in females sits inferior to uterus
-Internal urethral sphincter: Controls flow of urine from bladder into urethra
-Urethra: Tube from floor of bladder to exterior
-External urethral sphincter: Part of pelvic floor mm., controls flow of urine out of urethra
Internal Urethral Sphincter
Controls flow of urine from bladder into urethra
Urethra
Tube from floor of bladder to exterior
External Urethral Sphincter
Part of pelvic floor mm., controls flow of urine out of the urethra
Elimination/The Micturition Reflex
-Micturition/Urination/Voiding: discharge of urine
-Pressure within bladder stimulates stretch receptors which initiate reflex via PaNS - bladder contracts, internal sphincter relaxes
-Bladder filling gives a sensation of fullness before micturition reflex occurs
-After early childhood, we have conscious control
Micturition/Urination/Voiding
Discharge of urine
Incontinence
-Urinary incontinence: lack of voluntary control over micturition
Causes:
-Increased abdominal pressure (stress incontinence)
-Nerve damage
-Aging
-Disease/Injury
-Some medications
-Smoking
Urinary incontinence
Lack of voluntary control over micturition
Aging & Urinary system
-Kidneys decrease in size
-Renal blood flow & GFR decrease
-Glomeruli become less (or non-) functional
-Kidney diseases become more common
Diuretics
-Substances (including medications) that decrease reabsorption of water
-Medications, food/drink
Dialysis
-Artificial cleansing of the blood
Gynaecology
Specialized branch of medicine concerned with the diagnosis & treatment of diseases of female reproductive system
Urology
Male & female urinary systems & male reproductive system
Gamete
Germ cells (sperm in males, egg in females) that combine to form offspring
Embryo
Developing organism from fertilization to end of 8 weeks
Fetus
Developing organism (in utero) from 9 weeks to birth
Male Reproductive System
-Scrotum
-Testes
-Epididymis
-Ductus Deferens (Vas Deferens)
-Seminal Vesicles
-Prostate
-Bulbourethral Glands
-Urethra
Scrotum
Sac of loose skin & CT that supports testes - contains muscles that contract in response to cold to elevate the testes (or relax to lower them)
Testes
Site of sperm production - Within testes are cells that produce testosterone
Epididymis
Temporary storage site for immature sperm - it covers posterior & superior testis
Ductus Deferens (Vas Deferens)
Tube that sperm travel through - runs from epididymis into pelvic cavity, over & behind the bladder to urethra
Seminal Vesicles
Located at base of the bladder, they produce seminal fluid which nourishes sperm
Prostate
normally about size of a golf ball, it encircles urethra just below bladder - functions to secrete fluid into urethra that supports sperm function
Bulbourethral Glands
Below prostate, they secrete mucous to lubricate urethra & an alkaline fluid to neutralize acids from urine in urethra
Urethra
Transports Sperm (and urine) to exterior
Female Reproductive System
-Ovaries
-Fallopian (uterine) Tubes
-Uterus
Ovaries
On either side of uterus, produce eggs & hormones - ligaments hold them in place
Fallopian (uterine) Tubes
Extending laterally from uterus, they receive the ovum & provide site for fertilization
-They don’t connect to the ovary - they connect to superior uterus - ligaments hold them in place
-Peristalsis & movement of cilia transport ovum to uterus
Uterus
In pelvis between bladder & the rectum
-Receives, retains & nourishes fertilized egg
-Supported by ligaments (broad ligament, round ligament anteriorly, uterosacral ligament posteriorly)
-Thick wall of uterus has 3 layers - inner layer is endometrium which is the site of implantation of embryo - without pregnancy, it sloughs off as part of menstrual cycle
Mammary Glands
-Located in breast tissue superficial to pectoralis major & serratus anterior & are attached to them by a layer of deep CT
-Supportad by Cooper’s Ligament which anchor skin the the deep CT
-Modified sudoroferous glands, function to produce milk
Lactation: Synthesis & ejection of milk
Production is controlled by: Prolactin
Ejection is controlled by: Oxytocin
-Female sex hormones (primarily estrogens) increase mammary gland size at puberty
-Present in males & females but only functional in females
Lactation
Synthesis & ejection of milk
Milk production is controlled by
Prolactin
Milk Ejection is controlled by
Oxytocin
Definitions for Stress
-“The non-specific response of the body to any demand for change”
-“Physical, mental, or emotional strain or tension”
-“A condition of feeling experiences when a person perceives that demands exceed personal & social resources the individual is able to mobilize”
-Eustress: ‘good’ stress
-Distress: ‘bad’ stress
Eustress
‘good’ stress
Distress
‘bad’ stress
Stress Response (General Adaptation Syndrome)
-The wide-ranging set of bodily changes, triggered by a stressor that gears body to meed an emergency
-Stressor: any stimulus that produces a stress response
-Stressors can be internal or external
-Stress response is normal but is designed to be an acute response
-Contemporary stress is more insidious because it’s more physiology than physically driven
Stressor
Any stimulus that produces a stress response
Factors Affecting Stress & The Stress Response
Nature of the stressor & state of person being stressed determine stress response…
-Time
-Thoughts, moods, feelings & beliefs
-Your perceptions of the stressor
-Physical State
-Disease States
-Inadequate Sleep
-Age
Stress Responses
-Increased HR
-Increased Fluid Retention
-Increased BP
-Redirection of blood floe (increased to brain, heart, lungs, skeletal muscles - decreased to viscera, skin)
-Bronchodilaton
-Mobilization of energy substrates
Alarm Stage (a.k.a. fight or flight)
-Short lived
-Hypothalamus increases SyNS firing
-Adrenal Medulla: epinephrine, norepinephrine
-Mobilizes resources to relevant organs (brain, skeletal muscles, heart) for immediate activity
-Digestive, urinary, reproductive systems are inhibited
The Resistance Stage (a.k.a. resistance reaction)
-Longer lasting
-Initiated by hypothalamus
-Enhances & prolongs effects of SyNS
-ACTH: adrenal cortex is stimulated to release more cortisol
-hGH: lipolysis, glycogenolysis
-Glucagon: Increases blood glucose
-TSH: Increases glucose utilization
-Helps get us through a stressful phase
Adrenal Medulla
epinephrine, norepinephrine
ACTH
adrenal cortex is stimulated to release more cortisol
hGH
lipolysis, glycogenolysis
Glucagon
Increases blood glucose
TSH
Increases glucose utilization
Exhaustion Stage
-Resources get depleted & can’t support resistance
-Prolonged elevated cortisol levels can lead to muscle wasting, immune suppression, ulceration, pancreatic beta cell failure
-Pancreatic reactions may persist even after stressor is removed
Stress & it’s Effects
-If part(s) of homeostatic control system are dysfunctional, homeostasis may not be maintained (or is harder to maintain)
-If moderately affected, disease states occur
-If severely affected, death is possuble
Increased Stress
-Longer healing times
-Poorer healing
-As you age, the ability to maintain & (when disturbed) return to homeostasis decreases
Stress & Disease
Exact mechanisms are not well established but effects of stress can clearly predispose you to (or be an exacerbating factor for) certain ailments
-Rheumatoid Arthritis
-Immune suppression
-MSK (TMJ, HA, torticollis, increased muscle tone)
-CV conditions (hypertension, CAD, AHD
-GI dysfunction
-Metabolic syndrome
-Diabetes
-CNS conditions (CP, MS, Parkinson’s, epilepsy…)
-FM, CFS
-Insomnia
-Anxiety
-Depression
-Irritability/personality changes
-Unhealthy behaviours (excessive or abusive use of alcohol and/or drugs, smoking, decreased excercise, poor nutritional choices…)
-Obesity
Impact of Massage Therapy
-De-stress
-Improved sleep (which through the endocrine system facilitates healing)
-Improved digestion
-Help maintain healthy systems (immune, renal, CV, CNS, etc…)
-Maximize healing & quality of healing
-Help prevent disease states/exacerbation of diseases
Massage and Stress
Tools we can use
-Massage
-Hydrotherapy
-Breathing Techniques
-Stretching (esp. static stretching)
-Joint mobilizations
Element of hands on techniques that can be effective
-Rate (slower techniques)
-Transitions
Other treatment factors
-The way you communicate
-Temperature
Energy Systems
-ATP is split into ADP + Pi + Energy - the energy is used to power cell functions
-To use the ATP again, you have to reform it (ADP + PI + Energy = ATP)
-Cells reform ATP by one of 3 metabolic pathways:
1. Phosphocreatine (PCr)
2. Anaerobic cellular respiration
3. Aerobic cellular respiration
-PCr system is unique to muscle fibres
-All cells can produce ATP using anaerobic and aerobic pathways
-Energy systems work together to generate ATP but one system is usually less dominant based on the demand (e.g. sprinting vs. walking)
Cells Reform ATP by one of 3 Metabolic Pathways
- Phosphocreatine (PCr)
- Anaerobic cellular respiration
- Aerobic cellular respiration
Phosphocreatine (PCr) System
-PCr is a molecule that stores high amounts of energy in chemical bonds
-When PCr is split by enzyme, energy released is used to reform ATP
-Happens very fast therefore PCr is first energy pathway used
-Provides energy for 3-15 sec of maximal contraction
-No oxygen needed, no lactic acid produced
Anaerobic Glycolysis
-When muscle activity continues & PCr is depleted, glucose is used to make ATP
-Cells break down glycogen stored in their cytoplasm/sarcoplasm or glucose from blood & energy released in breaking them down is used to reform ATP
-Making ATP from glucose occurs in cell cytoplasm is called glycolysis
-One molecule of glucose is broken into 2 molecules of pyruvic acid & 2-3 ATP
-If oxygen is present, pyruvic acid enters the mitochondria where it undergoes series of reactions (that require oxygen) called aerobic cellular respiration
-During heavy exercise/demand, not enough oxygen is available (‘hence anaerobic’)
-In absence of oxygen, pyruvic acid does not go into mitochondria instead is converted into lactic acid/lactate
-Lactic acid diffuses out of the cell into the blood where is used by other cells or converted back into glucose in liver
-No oxygen required and producing lactic acid + anaerobic lactic
-Capable of supplying energy for 30-40sec
Lactic Acid/Lactate
-Metabolic by-product of anaerobic metabolism
-At lower levels of activity, lactate does not accumulate
-It is also converted back into to glucose/glycogen in liver (the Cori cycle)
-Lactic acid has a 1/2 life of 15-25 min & is cleared in (at most) a matter of hours
Aerobic Cellular Respiration
-This pathway is active when you are able to get oxygen into the cells (e.g. at rest or at low-moderate intensity exercise)
-Oxygen is delivered by myoglobin or from oxygen diffusing from blood
-In the presence of oxygen, pyruvic acid enters the mitochondria and in a series of reactions (that uses oxygen), produces much more ATP (much more than glycolysis)
-Carbohydrates, fats, & proteins can be usedin this process to make ATP
-Carbohydrates yield relatively little ATP
-Fats yield a lot of ATP
Proteins aren’t used readily (often not even included)
-At rest, cells of the body use aerobic metabolism to generate their ATP
-In activities that last longer than 10 min, most (90%) of ATP generated comes from aerobic system
Physical Exercise
-A single acute bout of activity that requires energy expenditure above resting levels
-Typically planned and structured
-Designed to improve or maintain one or more components of physical fitness
Acute Exercise Response
-How body responds to a single bout of excercise
Training Adaptations
-How body responds over time to the stress of repeated bouts of exercise
Repititions (‘reps’)
-Number of times a particular movement is repeated
Sets
Number of repetitions grouped together
“…to Faliure”
Performing a given exercise until you cannot perform another repetition with proper technique
Muscular Strength
-Ability of contractile tissue to generate tension (contract)
-Often viewed in the context of the maximum force that can be generated by a muscle or muscle group with one contraction
-Functional strength is the ability of the neuromuscular system to generate & control forces during functional activities
Muscle Endurance
-Ability to produce low intensity repeated activities over prolonged time frames
Flexibly
Ability of a joint or series of joints to move through a full ROM without injury
Basic Responses to Acute Exercise (in the apparently healthy person)
-Heart Rate: During exercise, increases directly in proportion to thee intensity of the exercise (there is a natural limit)
-Blood Pressure: Systolic increases, diastolic doesn’t change appreciably (Note: significant increases in blood pressure are seen with holding breath on exertion) (e.g. during resistance training exercise)
-Blood flow: Increases to the working structures, & is decreased to viscera
-Ventilation: Increases during exercise
Basic Responses to Acute Exercise (in the apparently healthy person) *HEART RATE
Heart Rate: During exercise, increases directly in proportion to thee intensity of the exercise (there is a natural limit)
Basic Responses to Acute Exercise (in the apparently healthy person) *BLOOD PRESSURE
Blood Pressure: Systolic increases, diastolic doesn’t change appreciably (Note: significant increases in blood pressure are seen with holding breath on exertion) (e.g. during resistance training exercise)
Basic Responses to Acute Exercise (in the apparently healthy person) *BLOOD FLOW
Blood flow: Increases to the working structures, & is decreased to viscera
Basic Responses to Acute Exercise (in the apparently healthy person) *VENTILATION
Ventilation: Increases during exercise
Training Adaptations (in the apparently healthy person) *MUSCULAR STRENGTH
-Initial strength gains are due primarily to neural adaptation (often rapid - within 4-8 weeks)
-Neural Adaptation: Motor learning, increased rate and synchronization of firing
-Subsequent increases are due primarily to hypertrophy
-hypertrophy comes after the initial gains & is from increased protein content (i.e. actin, myosin)
-Tendons, ligaments get stronger
Training Adaptations (in the apparently healthy person) *MUSCULAR ENDURANCE
-Increased muscle capillarization
-Increase in number & size of mitochondria
-Increased energy substratestorage (PCr, fats, glycogen)
-Tendons, ligaments get stronger
Training Adaptations (in the apparently healthy person) *FLEXIBILITY/RANGE OF MOTION (ROM)
-Ongoing increased flexibility/range of motion
-Improperly applied, there is a risk of hypermobility
FITT
Frequency - How often the exercise is performed per day or per week
Intensity - how hard someone is working
Time - How long the activity is performed
Type - What is the activity being performed
(FITT) Frequency
-Appropriate frequency depends on the goal, mode of exercise (strength training, aerobic etc.), & intensity
-e.g. post. surgical muscle setting (to offset atrophy, maintain neural pathways) may require low weight, low repetition isometric exercises multiple times per day
-e.g. standard weight, standard repetition resistance exercises (to improve strength) usually require a day of recovery in between
-e.g. maintenance of strength may require higher intensity exercise with 2-3 days recovery in between
-e.g. performance related cardio training: higher% HRmax, 3-5x per week
-e.g. health related cardio fitness: 60% HRmax, daily (one session or spread out over 10 min bouts)
(FITT) Intensity
Muscle strength training : 6-12 reps (to failure), 2-3 sets
Muscle endurance training: 15-50 reps (to failure), 3-5 sets
-Aerobic training: 30 min, 60-80% HRmax
(FITT) Time
-How long the program is being done for (weeks - months)
-Note adaptations & goals
(FITT) Type (mode)
Resistance training, balance/proprioception training, aerobic training
-Specifics (e.g. strength, endurance, isometrics, running, swimming, walking)
(FITT) Rest Interval
-Amount of time between sets
-This ranges from 1-2 min (low intensity exercises) to 4-5 min (high intensity exercises)
Training Principals
Specificity - select exercises that is best suited to meeting the goal
Overload - to achieve the goal , you must challenge the system beyond it’s current level (manipulate FITT)
Recovery - allow sufficient time between exercises (sets & days/week)
Progression - to achieve the goal, you have to move beyond the adaptation
Maintenance - once the goal has been achieved, it can be maintained with a reduction of 1/3-2/3 frequency as long as the intensity is maintained
Detraining
-‘The partial or complete loss of training-induced adaptations’
-Adaptations are reversible
-Detraining may occur for many reasons (lack of compliance, injury, illness)
Delayed Onset Muscle Soreness (DOMS)
-Muscle tenderness, pain on palpation, stiffness after exercise
-Typically starts about 8 hours after, peaks in 24-48 hrs & dissipates in a few days
Not fully understood but there are theories - the current models include the following factors:
-Unaccustomed high intensity exercise (esp. eccentric exercises) causes damage to structural proteins in the muscle fibres
-Inflammatory & immune processes activate
-These processes (esp. the fluid accumulation) also irritate nerve endings (causing pain)
