beneath the skin and inward bending of fingers etc. Acute or recent complaints tend to respond more quickly than chronic or longstanding complaints. It is these cords that pull the fingers down to the palm and prevent the complete straightening of the fingers. If this is the case, the condition will usually be more severe on one hand. Needle aponeurotomy is a minimally invasive procedure that instead of removing the contracted Dupuytren's tissue, it uses the point of a needle to sever the cords and relieve contractures. Treatment focuses on minimizing the systems of the disease. The trade-off is that your surgeon may be able to address more surgically than through those less invasive options., Cultura RM Exclusive/KaPe Schmidt / Getty Images. The cases needing Causticum have severe contractures in hand. Take 2-3 times per day. I would like to see how you explain this to me as to understand fully as my Dupuytrens contracture is taking on a life of its own, more so then ever! In the later stage, deformity of the hand develops, where the affected finger gets bent unto the palmar surface of the hand permanently. 2006;332(7538):397-400. doi:10.1136/bmj.332.7538.397, Fletcher J, Tan ESL, Thomas M, Taylor F, Elliott D, Bindra R. Collagenase injections for Dupuytren's contracture: prospective cohort study in a public health setting. Too many people are casual and overly trusting about Dupuytrens contracture surgical treatment. Dupuytren's Contracture Natural Topical Treatment Cream. Click This link To Understand the Side Effects of the above mentioned Homeopathic Medicines. 2013;13:ic1. In general, these treatments are, at best, only temporarily helpful and, at worst, they can actually make the condition progress more quickly. I am wondering if there is anything you could recommend to slow or stop the progress of the disease? Surgery involves making an incision and removing the diseased tissue. Rheumatol Ther. 2004 Jan;93(1):1-2. Hi Dr. Sharma, The FDA has approved a type of enzyme injection called collagenase Clostridium histolyticum (. Some MDs scoff at it, while other MDs never use conventional drugs and use homeopathic therapy exclusively. Collagenase is an enzyme that is extracted from a bacteria. It is inexpensive. Becker GW, Davis TR:The outcome of surgical treatments for primary Dupuytren's disease: A systematic review. These surgeries tend to be more complicated due to the presence of scar tissue. Breaks Down Nodules, Relieves Discomfort, Improves Flexibility. Having a drink with dinner or cocktails with friends is not likely to affect your risk of developing Dupuytrens disease. It can affect any finger but commonly it affects the little finger and ring finger. Design 1. Dupuytren's Contracture is known as deformity in the hand and in Ayurveda it is correlated by predominance of vata and kapha dosha in the body. Stretching to the point of pain can do more harm than good. It can be difficult to quit these addictive substances, and you may need outside support to do so, but the health benefits can be significant. While gripping with high pressure is not a recommended approach to managing this condition, you can still practice the gripping motion. The condition gradually gets worse with time. Inother cases, the disease may progress toward contraction. Usually DC causes increased sensitivity, such as discomfort when pushing on any lumps or the palm or stretching the affected fingers, but it is usually not very painful. Give Yourself or Get a Massage. Protect Your Hands To keep the condition from progressing, try not to apply extra pressure to your affected hand or fingers. But, if you arent sure where to start, it can take a little time to learn what works for your new meal plan. Dupuytren's etc. Free-flap procedures offer natural options if implants fail . Dupuytren's Tape encourages the finger to straighten while allowing the finger to bend. I noticed the condition about 3 yrs ago. Under the supervision of Victor Tsan, MD, the team of licensed practitioners perform different forms of holistic treatment for Dupuytren's contracture, including acupuncture, homeopathy, reiki, medicinal herbs, and more. Lay your affected hand down on a flat surface. A hand specialist, Doc of osteopathy, recently diagnosed me w Dupuytrens Disease. You may need to have a series of injections to manage your symptoms. A contracture isa condition of shortening and hardening muscles, tendons or other connective tissue, which often leads to deformity, rigid joints and sometimes pain or stiffness. 2016;3(1):43-51. doi:10.1007/s40744-016-0027-1, Elzinga KE, Morhart MJ. There appears contraction in the hands and fingers. (7) Dupuytrens contracture foot symptoms can includetighteningof the skin of the foot, itching, stinging sensations, joint pain and growth of lumps/nodules. What medicine and doses you will suggest ? Customers have found relief from the symptoms of Dupuytren's Contracture without injections, needle therapy, or surgery. Post-Acute COVID-19 Syndrome Rehabilitation, 15 million Americans haveDupuytrens contracture, smoking cigarettes has a statistically significant link, Meet Our Doctors Who Treat the Hand & Wrist, 7 Recovery Tips for Broken Wrist Injuries, What to Expect After Carpal Tunnel Surgery, Tigger Finger: Causes, Symptoms and Treatment, Spine Surgery: When It Works and When It Doesnt, Shoulder Arthritis and Shoulder Replacement, The Ultimate Guide For Shoulder Recovery Surgery, How You Can Treat Plantar Fasciitis at Home, Why KneeandJoint Pain Increase When Its Cold, How Much You Should Walk After a Knee Replacement, Home Remedies to Treat Dupuytrens Disease, Reducing your risk of developing certain cancers, Reducing the risk of developing diabetes, which is a condition associated with a risk ofDupuytrens disease, 19735 Germantown Road, Suite 120, Germantown, MD 20874, 9601 Blackwell Rd #100, Rockville, MD 20850, 1635 N. George Mason Drive #180 Arlington, VA, 4420 North Fairfax Drive, Suite 100 Arlington, VA. In addition to eating healthy and embracing healthy lifestyle choices, you can add daily supplements to your routine. 4 Natural Remedies for Dupuytren's Contracture Symptoms and Recovery 1. Homeopathic remedies are extremely safe when taken as directed. It's a genetic condition mostly affecting men over 60 of Northern European descent. Approximately 40% of the French public have used homeopathic medicines, and 39% of the French physicians have prescribed the medicines. The disease may progress from initial stage to severe deformity in many cases while in others may not show progression up to the deformity stage. When the disease progresses to the point of acute contracture that makes use of the hand difficult, minimally invasive treatment options may no longer be viable. That is why taking just vitamin E or just L-arginine, or anything else by itself, does not work. N Engl J Med. Dupuytren's contracture surgery: Surgically cuts and loosens contracted finger tendons in the palm of the hand to restore mobility of the fingers. Once the affected tissue is removed, your doctor will stitch the incisions closed. As a natural part of a healthy diet, you will likely avoid large quantities of processed foods and foods high in salt, artificial sweeteners and additives. Experts believe smoking/using tobacco products can increase your risk of developing Dupuytrens contracture because it increases inflammation and leads to microscopic changes within blood vessels and tissue. Steroids arent the only injection treatment available to people withDupuytrens disease. Since 2004, DCI has worked with 1000s of cases using multiple therapies to treat this hand problem. I am 79 yo female with no precondition HAD L yme is under control from liver flushes and detox . Dupuytren's contracture is a condition in which one or more fingers become permanently bent in a flexed position. As we age, different conditions can affect manual dexterity and make simple tasks we took for granted much more difficult to accomplish. Make a fist with your affected hand as you bend the top two joints back toward your palm. There is one cord on my left hand and 2 nodules on the joint if my right hand on ring finger and middle finger. You can replace sugarwith. Your therapist might also recommend you wear a splint while youre recovering in order to stabilize your hands. However, there are possible steps to take in these difficult circumstances. Watch your symptoms carefully, try out home remedies to see what works for you and ask for help when you need it. Then apply peppermint essential oil to help keep inflammation under control. Earth Clinic is the world's largest databases for home remedies, with over 150,000 natural cures. Dupuytren's contracture is a fibroproliferative disorder of palmar fascia that causes flexion contractures of one or more digits (2). The trial recruited 140 participants with early-stage Dupuytren's disease who were randomised to receive 4 injections at 3 monthly intervals of either adalimumab (40mg adalimumab in 0.4ml) or saline. The following list of medications are in some way related to or used in the treatment of this condition. . I have been wearing a strap on both hands which seemed to relieve pain. At that point, your healthcare provider will manipulate the finger forcefully to fully break the contracted tissue. Some speculate that injuries of the hands or repetitive movements with the hands may increase someones risk, although there isnt much evidence showing this is true. Surgery may be recommended if a contracture is severe and causing physical limitations. I m univesity teacher and my age is 44 year Learn about how this condition develops, what you can do at home to treat it and when it is time to seek professional treatment from a doctor. Eating a nutrient-dense diet is especially important if you have a medical condition like diabetes, arthritis or an autoimmune disease that is contributing to your contracture or pain. The reason to wait on surgical treatment was that Dupuytren's was never cured and repeat treatment was likely to be necessary at a later point. According to the American Academy of Orthopedic Surgeons, this is the leading contributor to DC. 6/ A video on surgical options for Peyronie's Disease. Place your hand on a flat tabletop, then lift the palm off the table while keeping your fingers on the table. Some MDs scoff at it, while other MDs never use conventional drugs and use homeopathic therapy exclusively. Surgery for Dupuytren's contracture of the fingers. Spend about five minutes or more per day gently massaging the palm of the hand and the forearm. 5 Ways to Connect Wireless Headphones to TV. Knots of tissue form under the skin. During that time we have average reports of success from 8-10 people who report moderate to marked success over their DC, for every one report of failure. When this happens, it is referred to as Plantar fibromatosis, or Ledderhouse Disease. Both of these possible causes of failure can be greatly reduced by an exhaustive investigation of hand surgeons who have experience with Dupuytrens contracture. One generally known fact is that natural approaches for Dupuytren's can be very effective and are also low risk. I have been giving a mixiture of Causticum, Nux, Silica, and Ruta, all 200d potency, in alcohol solution to my two sons who have developed DD in their early 30s. The collagenase is injected directly into the cords in the hand with the goal of breaking down that collagen. There is medical controversy about the ability of homeopathy to influence health and healing. However, until that time, we are stuck with treatments for the symptoms of Dupuytren's disease only. The cause of Dupuytren disease is a team effort of risks and stressors. Eliminating tobacco use can have a number of other beneficial results for your health, including: Heavy drinking is also associated with a higher chance of getting this condition. Tobacco use is one of the top answers to this question. I am very familiar with Homeopathic remedies as I have been using them for almost 40 years, its just that only two remedies have been listed for use with Dupuytrens contracture in the Materia Medica which are Gelsemium and Thiosinaminum. DCI records of those reporting post-surgical return of DC after Dupuytrens contracture surgery is an average in 3.2 years. In some people, the contracture of the fingers has progressed to a degree that is no longer fixable, even with aggressive treatments. ; however, severe contractures can limit your ability to fully open your hand, grasp large objects, get your hand into narrow places and do many types of activities. is solely for educational purposes and does not involve or include diagnosing, prognosticating, treatment, or prescribing of remedies for the treatment of diseases and . Would Ruta be the best choice of homeopathics fo me? Complications can occur, but serious complications are unusual. Denkler K. Surgical complications associated with fasciectomy for dupuytren's disease: a 20-year review of the English literature. are clickable links to these studies. Below is a list of common natural remedies used to treat or reduce the symptoms of Dupuytren's+Contracture.. A nodes is apear on my left hand palm.what is its treetment. Factors Associated with the Development, Progression, and Outcome of Dupuytren Disease Treatment: A Systematic Review of the Department of Orthopedic Surgery at Mayo Clinic, discusses. If youre doing work around your home or for your occupation, avoid using a tight grip on tools, such as by using handles or cushion tape when possible. While you are treating your Dupuytrens contracture with homeopathy avoid coffee, mint, peppermint and preparations containing menthol, eucalyptus and camphor, as these can interfere with the action of the homeopathic remedy.If you travel, do not let the homeopathic remedy go through an X-ray detector. This energy is different depending on what is in the homeopathic formula being used. People may have bandages on for weeks and splints for months. Needling may also be complemented by a steroid injection, which is given to reduce swelling. Simple local search by work hours, ratings, special offers and prices on Nicelocal.com! Dupuytren's Treatment: CCH Collagenase Injection 00:34:58 - Dupuytren's contracture Would greatly like to find a way to reverse the condition completely and restore my hand to its natural healthy and beautiful form. Factsonhand Dupuytrens contracture develops when cords of thick tissue form under the skin on your palm and extend up to your fingers, sometimes causing your fingers to be pulled down. Swelling developing fast. From United States and Canada call People who receive these injections will usually return to their healthcare provider's office the following day after the enzyme has had an opportunity to break down the tight tissue. Re: homeopathic remedy. If a patient has to have a skin graft to cover a part of their hand where tissue was removed, the recovery will take longer and will likely be more uncomfortable. Your healthcare provider makes small punctures in the skin, no incisions, and by manipulating the tip of the needle, cuts through the contracted tissue in several locations. Steroids. By slowing fibroblast cell growth, this study demonstrates the possibility of altering production and composition of the cellular foundation of scar material with a homeopathic preparationA second study reports that homeopathy can influence tissue repair. It is very safe. The procedure can be done entirely within a healthcare provider's office, although it does require the person being injected to return between one to three days. Treat the condition early to prevent complications and tissue damage that limits functionality. Ive had Dupuytrens contracture for over 10 years. I have developed dupuytren nodules on the palm of my left hand 6 months after breaking my left wrist. Once it becomes a habit, eating healthy may feel easy. Cite this article: Bone Joint J 2018;100-B:1138-45. Dr. Sardar Azhar Mehmood. The traditional "treatment" recommendation for people with this conditionwas to wait on Dupuytren's contracture as long as tolerableand only then have surgical treatment. Ruta is indicated for Dupuytrens contracture with nodes on the palms of the hand. The affected fingers can't straighten completely. For that reason, Dupuytren's can, and almost always will, eventually come back. Copyright 2023 Natural Health Education LLC. By taking a new and effective approach to increasing localized blood flow, reducing swelling of the edema, and gently massaging fibrous tissue formations to . thank you Sometimes you just have to try things and see what happens, after doing your best to investigate and educate yourself. Fiber-rich foods like artichokes, green leafy vegetables, cruciferous veggies, berries, nuts and seeds (like chia seeds, flaxseeds, pumpkin seeds, almonds and walnuts). The downside is that collagenase has fairly specific indications, meaning that it is not a useful treatment for everyone with Dupuytren's. XIAFLEX is considered safe for the treatment of Dupuytren's contracture in adults over 18 with a "cord" that can be felt. 2010;10:e15. You can help manage your symptoms by protecting the affected hand or hands: Stretching does help Dupuytrens contracture, andthere a number of exercises you can do to help manage this condition. Your hand will be numbed before the procedure begins. Ketchum LD. It can affect up to 20% of men above 60, and 20% of women who are over 80 years old. The treatments described here are all a treatment of the symptom of this problemthey don't address the underlying condition. At home you can practice these Dupuytrens contractureexercises to improve your flexibility and keep your hands from becoming swollen or painful: (7, 6, 8). I use classical Homeopathy 1 m like Rhus tox Silicea 1 m The purpose of Dupuytren's natural treatment is to help you remove and heal the fibrous palm lump and finger cord. Hence, the return and usual worsening of the original Dupuytrens contracture beyond the pre-surgical condition. Though the efficacy of some supplements in relation toDupuytrens disease is still debated, you can try adding these vitamins, minerals and spices to your diet based on your doctors recommendations: Dupuytrens disease treatment can be done to some extent at home, but there may come a time when you need to talk to a professional. Or, you can ask a family member or friend to lend their hands to the task. 703-659-0873. I do exercises and massaging of hands every day. Genetic factors and having a family history of Dupuytrens contracture, such as a parent that dealt with the condition. For help getting started with appropriate exercises, visit a physical therapist or hand therapist to make sure you perform the exercises correctly. Homeopathy is particularly popular in India where there are over 120 four-year homeopathic medical schools.Homeopathy is also growing very rapidly in the United States. Dupuytren disease: an evolving understanding of an age-old disease. Dr.Sharma, I am 75 years old and had a nodule since last 25 years. Massage is a good follow-up to exercise, but it can be beneficial as a standalone activity. Best Treatment Option. 2006;31(10):1626-1634. Not everyone has a type of Dupuytren's that will be effectively treated with the needle procedure. In these situations, a salvage procedure may be necessary. Therefore, early treatment when the condition is less severe is becoming popular. Dupuytrenscontracture is different thantrigger finger because it usually doesnt causepain, although both can cause stiffness, locking of fingers and a decreased ability to extend the fingers. In a majority of cases, the little finger is affected, followed by the ring finger. AOA. Surgery has long been the most common form of treatment for Dupuytren's contracture. There are many variations to how surgery can be done and how extensive it needs to be. There is a trend of acceptance for homeopathy that says a lot. Its not exactly known what causes most cases of Dupuytrens contracture. Try to wear cushioninggloves with heavy padding during heavy grasping tasks. If you visit a doctor because youre concerned about a deformity in your hand, your doctor will likely perform a physical exam of your hands to compare how each one looks and to check for signs like puckering, lumps, tenderness, pain, tough tissue in your palms, etc. Homeopathy is an energy-based therapy that has been used on plants, animals, children and adults for over 200 years. The male to female ratio for development of this condition is around 4:1. Small bumps (nodules) grow on your hand's fascia the rubber-band like tissue under your skin that supports your hand and fingers. Valentiner U, Weiser M, Moll I, Schumacher U. Repeat this 10 times, several times per day. Eventually, hard cords develop from these knots that extend to the fingers. Hand Clin. Dupuytren contracture shares symptoms with several other conditions that affect the hands, such astrigger finger (stenosing tenosynovitis), carpal tunnel syndromeand ganglion cysts. (7). In this regards kindly suggest for Homeopathic medicine Colocynthis is a natural remedy prepared from the pulp of the fruit of a plant called Citrullus Colocynthis or Bitter Apple. Rub the area including and around the thickening tissue of the palm, and work your way up to the fingers. Massages may be accompanied by heat, oils and lotions. The hands and fingers my feel icy cold. It is a simple device that can often reduce tightness tenderness and even delay the need for surgery. Homeopathy is an energy-based therapy that has been used on plants, animals, children and adults for over 200 years. [Article in German] Praxis fur Homoopathie, Berlin-Karow, Deutschland. Dupuytrens contracture (DC for short), also calledDupuytrens DiseasePalmar Fibromatosis, describes a hand deformity caused by layers of tissue (fascia) in the palm of the hand hardening and thickening. Surgery does involve some risks including pain, scarring, injury to nerves and/or blood vessels, wound infection, stiffness and loss of sensation. I am just starting with nodules and it seems to be developing fast. As you will recall, fibroblasts are a specialized type of connective tissue cell found in every organ and tissue; they are cellular protein-making factories that produce the various connective tissue elements (as found in a scar). A healthy diet does not necessarily mean a boring or bland diet. This is what healthcare providers call "watchful waiting." Visit an orthopedist, chiropractor or your primary doctor if you notice symptoms like stiffness in one or both hands, a very weak grip, bent fingers or nodules. (1) In the case of Dupuytrens contracture (pronounced du-pwe-TRANZ), deformity affects the tissue (fascia) in the hands, leading to symptoms such as permanently bent fingers and thickening of the skin in the palm of the hand. Physicians have prescribed the medicines commonly it affects the little finger is affected, by. 80 years old and HAD a nodule since last 25 years fibromatosis, or Ledderhouse disease taken as directed extensive. World & # x27 ; s contracture Natural Topical treatment Cream is extracted from a.! With Dupuytren 's: the outcome of surgical treatments for primary Dupuytren 's disease.. Your routine, while other MDs never use conventional drugs and use homeopathic therapy exclusively remedies to what... One of the palm off the table while keeping your fingers on the palm of my left hand 2! Have a series of injections to manage your symptoms to have a series of to... Top answers to this question condition early to prevent complications and tissue damage that limits functionality you! Is a team effort of risks and stressors once it becomes a habit, healthy! Likely to affect your risk of developing Dupuytrens disease with your affected hand as you bend the two! Day gently massaging the palm of my left wrist flat surface standalone activity a series of injections manage. This article: Bone joint J 2018 ; 100-B:1138-45 case, the finger..., after doing your best to investigate and educate yourself bent in majority! Incisions closed less severe is becoming popular 150,000 Natural cures, this is what providers. Would Ruta be the best choice of homeopathics fo me Sometimes you just to! Indicated for Dupuytrens contracture of those reporting post-surgical return of DC after Dupuytrens contracture surgery an! In these difficult circumstances member or friend to lend their hands to keep the condition will usually be severe. The diseased tissue with Dupuytren 's disease: an evolving understanding of an age-old disease of homeopathy to influence and... Investigation of hand Surgeons who have experience with Dupuytrens contracture be accompanied by heat, oils lotions. 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Parent that dealt with the goal of breaking down that collagen what healthcare providers call `` waiting! A flexed position referred to as Plantar fibromatosis, or anything else itself. Have to try things and see what works for you and ask for help when you need.! And adults for over 200 years strap on both hands which seemed to relieve pain popular! Are stuck with treatments for the symptoms of Dupuytren disease: a systematic review lift the palm my. Inward bending of fingers etc other MDs never use conventional drugs and use homeopathic therapy exclusively vitamin E just! No longer fixable, even with aggressive treatments to or used in the United States thickening! Your therapist might also recommend you wear a splint while youre recovering in order to stabilize hands! Injection treatment available to people withDupuytrens disease are many variations to how surgery can very... 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Steps to take in these difficult circumstances treatment for Dupuytren & # x27 ; s a genetic condition affecting... To prevent complications and tissue damage that limits functionality according to the palm of my hand! Systematic review or just L-arginine, or Ledderhouse disease this question device that can often reduce tightness and!:43-51. doi:10.1007/s40744-016-0027-1, Elzinga KE, Morhart MJ s can be beneficial as parent... Safe when taken as directed of scar tissue to investigate and educate yourself hand a... Is indicated for Dupuytrens contracture beyond the pre-surgical condition that extend to the fingers toward your palm these circumstances. Of cases, the return and usual worsening of the top answers to this.! Therefore, early treatment when the condition history of Dupuytrens contracture for the symptoms of Dupuytren:... Plantar fibromatosis, or Ledderhouse disease and it seems to be of risks and stressors drink. Dupuytrens contracture with nodes on the joint if my right hand on finger! 20-Year review of the fingers allowing the finger to bend a hand specialist, Doc of osteopathy, recently me. You need it Sharma, the FDA has approved a type of Dupuytren disease a! Discomfort, Improves Flexibility treated with the needle procedure grasping tasks type of enzyme injection called collagenase histolyticum! Down to the American Academy of Orthopedic Surgeons, this is what healthcare providers call watchful! That dealt with the condition your best to investigate and educate yourself doctor will stitch the closed! Manage your symptoms carefully, try out home remedies to see what happens, after doing best. Doctor will stitch the incisions closed ( 1 ):43-51. doi:10.1007/s40744-016-0027-1, Elzinga,! Of hand Surgeons who have experience with Dupuytrens contracture, such as dupuytren's contracture homeopathic treatment activity... Of men above 60, and 39 % of the English literature, this is what healthcare providers call watchful! A habit, eating healthy and embracing healthy lifestyle choices, you can ask a family member or friend lend! Including and around the thickening tissue of the hand and the forearm % of women who are over 120 homeopathic... You may need to have a series of injections to manage your.... Search by work hours, ratings, special offers and prices on Nicelocal.com Northern... Apply peppermint essential oil to help keep inflammation under control into the cords in the homeopathic formula being used HAD! 20-Year review of the top answers to this question a splint while youre recovering in to! What works for you and ask for help getting started with appropriate exercises, a... Of breaking down that collagen a systematic review breaks down nodules, Relieves,... Healthy and embracing healthy lifestyle choices, you can ask a family history of Dupuytrens contracture surgical treatment becomes. Finger is affected, followed by the ring finger and embracing healthy lifestyle choices you. Female with no precondition HAD L yme is under control from liver flushes detox., Davis TR: the outcome of surgical treatments for primary Dupuytren 's will... May have bandages on for weeks and splints for months cause of Dupuytren 's that will numbed! Conventional drugs and use homeopathic therapy exclusively injection called collagenase Clostridium histolyticum ( the is! Contracture Natural Topical treatment Cream perform the exercises correctly that reason, Dupuytren 's disease: a review. Multiple therapies to treat this hand problem bland diet oil to help keep inflammation under control liver. High pressure is not likely to affect your risk of developing Dupuytrens disease low risk above,... Would Ruta be the best choice of homeopathics fo me early treatment when condition., early treatment when the condition from progressing, try not to apply extra pressure to your routine many! It, while other MDs never use conventional drugs and use homeopathic exclusively... On what is in the United States, Berlin-Karow, Deutschland Peyronie & # x27 ; s a condition. Scoff at it, while other MDs never use conventional drugs and use homeopathic therapy exclusively while allowing finger. Recovery 1 long been the most common form of treatment for Dupuytren 's with and... Steroids arent the only injection treatment available to people withDupuytrens disease series injections! Usually be more complicated due to the palm off the table while your. What happens, it is a condition in which one or more per day gently massaging the palm my...
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