Time for the Big Talk. How's the CAA doing?

[starryeyes]

Unfortunately on p. 8 the CAA goes on more about CBT with questionable statements:

Cognitive Behavioral Therapy

CBT has been shown to be effective in managing CFS in small, short-term trials.[82] CBT may help CFS patients develop constructive coping strategies, better manage symptoms, improve their level of function, and enhance their ability to perform activities of daily life.[83,65] They can also learn to pace activity and make lifestyle adjustments to reduce the incidence of postexertional malaise and promote feelings of control and self-efficacy.[84]

* Manage patients' expectations of CBT. Studies of CBT in CFS show improvement in function and symptom management but very limited effect on pain and fatigue.

* Manage patients' responses to CBT. Some patients are resistant to this particular therapy because of early approaches in CFS that focused on errant illness beliefs, reinforcing for patients the idea that CBT therapists "believe CFS is all in your head." When patients realize that CBT is used as an adjunct therapy for cardiovascular disease, diabetes, cancer, orthopedic injuries, and other medical conditions, and that CBT may help CFS symptoms, they are more likely to be receptive to this therapy.

* Recommend CBT programs that focus on developing individualized activity programs that incorporate pacing and graded activity, and on coping behaviors, rather than programs that focus primarily on psychological factors.

* Be aware that increased symptomatology is the main reason cited for discontinuing CBT. This may be avoided if a paced, personalized plan is followed and activities are tailored to the individual's capabilities.

* Recognize that because CBT is often not covered by insurance, some CFS patients will not have access to formal therapy. In this situation, clinicians who understand CFS can provide information about the illness in general, lead individual patients to understand how their behavior is impacting the illness, and set up activity and exercise programs that are therapeutic.

They do finally address the severely ill:

Severely Ill Patients

A subset of people with CFS are so severely ill that they are largely housebound or bedbound. They require special attention, including a modified approach to exercise. Hand stretches and picking up and grasping objects may be all that can be managed at first. Gradually increasing activity to the point that patients can handle essential activities of daily living -- getting up, personal hygiene, and dressing -- is the next step.

Focusing on improving flexibility and minimizing the impact of deconditioning so patients can increase function enough to manage basic activities is the goal with severely ill patients.

 

[Gerwyn]

I finally decided to just take the test at the CAA for their newest CME and that's allowing me to view the other pages after subscribing to the link:

http://cme.medscape.com/viewarticle/581527_5

The answers aren't always apparent yet but some of them are with a graph showing how everyone who's taken it has responded and it's very revealing.

The first few pages looked very good, much of it is saying exactly what we are here but then I came to this part on p. 5:




Bummer!! :Retro mad: It does look like they are trying to explain a CBT that can truly be helpful to CFS patients but the term "CBT" is still being used against us and instead of explaining that, the CAA says: "Some patients are resistant to this therapy because they mistakenly believe health practitioners who prescribe CBT think CFS is purely a psychological illness."

So we look like we're just mistaken.

NO you are not mistaken


5. Consider cognitive behavioral therapy (CBT). The goal of CBT in the management of CFS is to help patients cope with their illness, change behaviors that can contribute to symptom expression, and develop an individualized activity plan to avoid postexertional malaise on one extreme and deconditioning on the other. While CBT is frequently prescribed as a coping strategy, it can also improve function and activity levels.

That statement is completely false.There is no scientific evidence in support of this whatsoever

 

[starryeyes]

Further down the page the CAA says:

Some patients become fearful that any exertion will trigger symptoms (kinesophobia), and thus become couch- or bedbound. This, however, only leads to stiffness, soreness, and severe deconditioning. Such individuals are encouraged to initiate a progressive program of stretches and range-of-motion activities and then add low-level physical activities like short walks or floating in a pool.

Oh nos!! Say it ain't so! See, this is what we mean. They DON'T get it!!!!! :In bed:

 

[Gerwyn]

This is another PEARL

Clinical Pearl
The telltale symptoms of CFS are profound exhaustion and postexertional malaise; significant muscle, joint, or headache pain; cognitive dysfunction; and sleep disturbance. Rule out other causes for the symptoms, and then apply internationally accepted case criteria to confirm the diagnosis. The occurrence of comorbid depression does not rule out a diagnosis of CFS. More than half of CFS patients become depressed at some point in the course of the illness.

FUKUDA does not make post exertional malaise a mandatory diagnostic criterea.Without that critera a poor GP has no way of telling whether the patient has CFS or PRIMARY depression.In the absence of PEM patients with primary depression fit the FUKUDA criterea perfectly!

 

[Gerwyn]

HOW IS THIS FOR CBT?

Although Cognitive Behavior Therapy (CBT) is widely recommended for patients with
ME/CFS, it is far from clear whether cognitive behavior therapy is helpful for most
patients.

The rationale for using CBT in ME/CFS is that inaccurate beliefs (that etiology
is physical) and ineffective coping (activity avoidance) maintain and perpetuate CFS
morbidity (Deale et al, 1997;Sharpe et al, 1996).

However, it has never been proven
that these illness beliefs contribute to morbidity in CFS.

Where correlations do exist it
is possible, even likely, that beliefs in physical etiology are correct and that activity
avoidance is necessary for the more severely ill (Lloyd et al, 1993;Ray et al, 1995).


Of the 6 reported studies using CBT in “ME/CFS” two selected patients as defined
by the Oxford (Deale et al, 1997;Sharpe et al, 1996) one using the Australian criteria
(Lloyd et al, 1993) and one using the Fukuda criteria “with the exception of the criterion
requiring four of eight additional symptoms to be present” (Prins et al, 2001).

These
methods of patient selection allow for considerable heterogeneity and inclusion of psychiatrically
ill patients with fatigue.

Therefore, the results may not be applicable to the
average Fukuda or Canadian defined patient.

Of the remaining two studies using valid
selection criteria, one found no benefit of CBT (Friedberg & Krupp, 1994).

The only study
reporting benefit (improved functional capacity and decreased fatigue) was conducted in
adolescents (Stulemeijer et al, 2005).

It is important to note that no CBT study has reported that patients have been
improved enough to return to work nor have they reported changes in the physical symptoms
of CFS eg. muscle pain, fever, lymphadenopathy, headache or orthostatic intolerance.


Furthermore, clinical experience suggests that trying to convince a patient with
ME/CFS that s/he does not have a physical disorder and should not rest when tired leads
to conflict in the doctor-patient relationship and poor outcome for the patients. Therefore
it would be prudent to await further research before recommending this CBT approach.
Psychiatric Treatment Guidelines—E. Stein, 2005

 

[usedtobeperkytina]

For a while, there was quite a stir when Dr Bruno felt that ME and post polio syndrome were indistinguishable. With ME being most likely enteroviral this made complete sense. The point of both was that they got worse with activity. The answer was to limit activity to the most essential. He felt that wheelchairs, stairlifts etc should be used as a first choice so that other things could be done. If you need to stand and cook save your energy for that by not climbing stairs. Whether there is any connection with post polio syndrome, the idea seems to have been dropped as PPS became more mainstream, this system, of management struck me as being the right way to go with ME.

So a patient with ME should be told to REST as much as possible. If counselling is needed for anything it is to help patients look at their life and see how they can simplify it. As was said, lots of us have found ways to use less energy while doing the activities of living. I can do much more now because I have worked out easy ways to do things. In general this probably means LESS walking :Retro smile: Time off work, walking frames with seats or other aids, an OT assessment of your home, a bus pass; these sort of things should be given as needed, the exact opposite of what happens now.

A document on the CAA website which is full of energy saving ideas would be of great practical benefit.

I agree with all of the above. That is why it needs to be mentioned in any information given to doctors or new patients. We have over time figured it out. But a newly sick person will try to push through and ignorant doctors will advise gradual exercise. So it needs to be putl out in a plain explanation of just what kind of body activity a severely sick person should and shouldn't do. Without that, the ignorant doctors will advise joining a gym. The CAA is not made for the Batemans, Petersons and Klimases.

Tina

 

[usedtobeperkytina]

A document on the CAA website which is full of energy saving ideas would be of great practical benefit.
Mithriel

I don't know about the Web site. But the first Chronicle I got told some helpful tips to perserve energy if you still worked. I think there were ten. Very helpful. And it helped me again to realistically look at what lifestyle changes I need to make.

Later issues of the Chronicle had similar articles. I miss the Chronicle.

Tina

 

[Cort]

As I remember the Chronicle frequently had energy saving tips.

Some patients become fearful that any exertion will trigger symptoms (kinesophobia), and thus become couch- or bedbound. This, however, only leads to stiffness, soreness, and severe deconditioning. Such individuals are encouraged to initiate a progressive program of stretches and range-of-motion activities and then add low-level physical activities like short walks or floating in a pool.

I'm not particularly excited about this but then again in a community of 1,000,000 people some people are going to do this. How could that not happen? Some people are depressed - there's going to be a range of reactions to CFS. I would imagine that many people who are bedbound who follow the appropriate 'exercise' therapy are probably still bedbound but are stronger for it and are less deconditioned, etc. There's no talk of a cure because there's no expectation - just improving their health a bit. They talk about starting 'range-of-motion activities' and stretching - things we wouldn't ordinarily think to do. Deconditioning is a terrible burden to place on a body. .

They also need to state that patients on the other hand are simply so ill that they become bedbound.

This is Dr. Bateman, Dr. Lapp and the CAA talking - those doctors have seen 1,000's of patients, Teej, I think they do get it about CFS. I know how its troubling but they're talking about one type of patient that they do come across not the general set of patients. Glad you like the program more than the last one

Thanks for clearing it up about Dr. Friedberg. I can see how that could be a problem. I like his program overall, though. I agree that most CFS patients don't have enough energy for 'exercise'; its all taken up with other activities - a very good point. As Dr. Friedberg notes most patients are doing too many activities - often simply to survive, bring in money, etc. ; they need to cut back if they can - not take on an 'exercise program". Good point!

While CBT is frequently prescribed as a coping strategy, it can also improve function and activity levels.

It suggests that CBT 'can' help do that -in some patients - and indirectly states that it doesn't in others. Its a qualifier and it follows these practitioners experience, in some patients, it does do that.

Imagine if they put 'does' in there instead - a different story indeed.

 

[Gerwyn]

Some patients become fearful that any exertion will trigger symptoms (kinesophobia), and thus become couch- or bedbound. This, however, only leads to stiffness, soreness, and severe deconditioning. Such individuals are encouraged to initiate a progressive program of stretches and range-of-motion activities and then add low-level physical activities like short walks or floating in a pool.

No kinesophobia is a highly speculative opinion posing as fact.Exertion triggering the symptoms is the fact

 

[justinreilly]

Or that the defintions of CBT and GET in the abstract, and application of those methods in real life by doctors who truly understand CFS, and application of those methods in real life by doctors who do NOT truly understand CFS, and mention of these methods in the media, and what people hear when those terms are used - that none of these are in alignment. There is a world of difference between "CBT and GET are all you need" and "There is no treatment for CFS; the best that can be done to ameliorate the illness in some people is CBT and GET." And of course, even if the terms are replaced or better defined, there is NO treatment that helps ALL people with CFS, or even the same person with CFS at different points in time.

I don't know if that is semantics or not, but this is what I understand Tina to be saying.

There is a difference, but both statements are incorrect and harmful and should not be anywhere advocated by CAA. That you, the director who is assigned to listen and communicate with us, still say things like this is yet another indication that this problem is really entrenched in CAA. If this type of message hasn't been either received or understood after the 900 posts on this thread and 300 posts on the other CAA thread, not to mention all the other input CAA has received from patients over the years, I don't think continued communication alone will be effective.

It is time for patients to step it up the pressure, by asking people to donate to WPI, not CAA until these problems are resolved.

I certainly agree that CBT can be helpful if applied correctly. But I now have come to agree with those who have posted here who say the term has become too polluted and must be abandoned. Obviously GET is very harmful to many as is of course to be expected based on PEM, one of the central features of ME/CFIDS.

A statement such as "Pacing and supportive counseling emphasizing pacing are the only therapies that have been shown to be helpful [or helpful to many and whose adverse reaction rate is low]" is what should be said. I'm beyond tired of waiting for this common sense stuff to be done by CAA.

 

[justinreilly]

Hi Doc

How about the following;
All chronic debilitating conditions can adversly affect the suffers psychological wellbeing.CBT is therefore as appropiate in ME as it would be in any other chronic debilitating illness
GET is as useful for ME patients as it would be for any other neurological disorder as defined by the WHO. Drs should also be aware of the potential for litigation should a patient suffer adverse effects as a result of recommending this unproven option.

Same information exactly but put in a more advocative manner!

I like this, with the exception that not all neurological illnesses are characterized by PEM. So one could say "graded exercise is as useful in treating ME as it is in any other disease in which graded exercise, or any other minimal exertion, increases morbidity." CAA should just say a more concise version of this: "GET is contraindicated in treating ME/CFIDS." Period.

 

[justinreilly]

Dr. Yes,

Would you consider applying for a CAA director slot? I am blown away by the knowledge and eloquence reflected in your posts!

 

[Lily]

Dr. Yes,

Would you consider applying for a CAA director slot? I am blown away by the knowledge and eloquence reflected in your posts!

You got that right!!!

 

[justinreilly]

That is what I am saying, ditch the confusing and loaded terms of GET and CBT completely.

Instead, say "professional counseling may be helpful to guide the patient in making adjustments and accepting the limitations of having a chronic and debilitating illness." I don't want to see CBT, even with caveat explanation of it anywhere in an authoritative CFS literature. Bad, bad word. Just leave it out. "professional counseling" is sufficient. And spelled out, it is fewer letters than cognitive behavioral therapy.

As for GET, I would avoid the word "exercise" because most people, no doubt docs included, think of aerobics and weight lifting as exercise. I would use "body activity".

But I do think the "exercise" issue needs to be addressed in information to patients and doctors, only because they will go the wrong direction based on understanding of fatigue in general, other illnesses and understanding of body. Diabetes has fatigue, yet exercise is good for them. Something needs to be in the literature to correct the paradigm.

The best helpful advice I got when I got sick was to not push it. I read a book by a dentist in Australia who had CFS and he talked about starting off not getting out of bed for three months. Wow, that's extreme, I thought. Then I went to FFC which recommended bed stretching, even finger push ups if that is all you can do. This totally changed my paradigm from the way I thought as a healthy person to making the changes I needed to start recovery. And, three years later, I had crawled out of the hole...

Tina

Exactly!

I love the recommendation of 'finger push ups', it really puts into perspective the limitations the more severly ill face while bringing a smile to the face, at least mine.

 

[Orla]

from from the CAA info (someone else quoted this, i have not read through all the info yet):

Some patients become fearful that any exertion will trigger symptoms (kinesophobia), and thus become couch- or bedbound. This, however, only leads to stiffness, soreness, and severe deconditioning. Such individuals are encouraged to initiate a progressive program of stretches and range-of-motion activities and then add low-level physical activities like short walks or floating in a pool.

Cort wrote:

I'm not particularly excited about this

>

It might be easy to not get too excited about it if you feel it is not about you. However this sort of nonsensical statement (re exercise phobia) needs challenging. This is not just because it is unsubstantiated CBT school rubbish, not just because the more severe a patient the more vulnerable they are to the abuse and ignorance of others (and at a time when they most need help), but also because this sort of thinking affects all of us.

[Edit: and the above statment gives the impression that peope become severe because of phobia. For people who are severe it could be very bad if everyone around them, that they are utterly dependent on, started to think this way, it could be a great excuse to neglect them and not meet basic needs.]

Once it is hinted at that some patients are phobically avoiding activity, the air of suspicion cloaks us all, whether we like it or not. Once this idea is out there at all as a serious idea, every time you see a new doctor, every time someone in authority makes a decision about your disability, housing, home help, testing or about any assistance you might apply for, they might have this niggling doubt at the back of their mind that maybe you could just do a bit more, and maybe you are just phobically avoiding activity, so maybe they are not helping you by giving you things.

There is no evidence that phobic avoidance of activity is a general problem in ME/CFS. Yes maybe you could find one in a million that fit this model to some extent (though if they have ME/CFS they still have a problem with exercise, whether they are phobic or not), but is it worth hanging the rest of us for this? This comment about phobia will only encourage and indulge the most ignorant doctors to feel that they were right all along, and it might put the idea into the heads of good doctors.

<Some people are depressed - there's going to be a range of reactions to CFS.>

Well then that is a depression problem and not an ME/CFS one, and once the depression is dealt with they still have ME/CFS so need to be careful about not overdoing it.

<

I would imagine that many people who are bedbound who follow the appropriate 'exercise' therapy are probably still bedbound but are stronger for it and are less deconditioned, etc.>

No they will very likely get worse from trying to exercise, unless they are improving naturally. I have known people to try very gentle exercises when bedbound and it was an absolute fiasco. Like the rest of us, if the severe patient improves they will start to do more. They are not more severe because they are phobic but because of the nature of the illness (and I am not saying there is not the odd patient out there who couldn't manage better, but again why hang the vast majority for this?).

<They talk about starting 'range-of-motion activities' and stretching - things we wouldn't ordinarily think to do.>

But there is no evidence that this is appropriate or helpful.

<Deconditioning is a terrible burden to place on a body>

Well not as bad as ME/CFS. And the word deconditioning is thrown about far too much. Muscle wastage is almost unheard of in ME/CFS and blood clots are rare. One difference between ME/CFS patients and patients with paralysis is that ME/CFS patients are normally moving around to some extent so they avoid some of the problems typically associated with deconditioning.

There are also other ways around exercise for dealing with some potential problems in the very severe, for example using splints where necessary. But some physio's can even resist this if they think the patient needs encouragement to do exercises (I know of more than one person this has happened to. I remember reading of one case where splints were removed, and the patient ended up with a problem than they need not have had, all because the people treating the patient thought they should be excercising).

Maybe, when more is known about ME/CFS physiology physiotherapy can be more safely administered but at the moment they are basically clueless about what they are doing treatment-wise, and it is all a guessing game, and as far as I am concerned our guess is better than theirs.

Orla

 

[gracenote]

Well said, Orla.

 

[starryeyes]

I agree with all of the above. That is why it needs to be mentioned in any information given to doctors or new patients. We have over time figured it out. But a newly sick person will try to push through and ignorant doctors will advise gradual exercise. So it needs to be putl out in a plain explanation of just what kind of body activity a severely sick person should and shouldn't do. Without that, the ignorant doctors will advise joining a gym. The CAA is not made for the Batemans, Petersons and Klimases.

Tina

Nor are they for me! Applauding your post Tina. You make excellent points.

 

[starryeyes]

Exactly!

I love the recommendation of 'finger push ups', it really puts into perspective the limitations the more severly ill face while bringing a smile to the face, at least mine.

When I think of finger push ups I cringe. My fingers hurt so much from this illness. It hurts to type too but not as much as bending them and stretching them all the way does.

This further illustrates that we are really in dire straits when this illness becomes severe. If a doctor recommended finger push ups to me I'd have to set him straight.

 

[Dr. Yes]

After talking about nutrition the CAA's CME goes on with more about Pacing etc... on P. 8:

http://cme.medscape.com/viewarticle/581527_8

Strength and Conditioning

A strengthening and conditioning program can reduce pain, prevent muscle spasms, increase strength and flexibility, improve balance, reduce falls, and enhance stamina and function in CFS patients.[78] Low-level exercise, including stretching, strength training, and simple resistance training, appears to be reasonably well tolerated by most patients, as long as they learn to avoid overexertion.

* Encourage patients to start with simple stretching and strengthening exercise, using only body weight for resistance. Gradually add wall push-ups, modified chair dips, and toe raises to the routine. Increase repetitions gradually. Patients can begin with a set of 2-4 repetitions and build to a maximum of 8.

* Add resistance exercise as strength improves. Exercise bands or light weights are both good options for simple resistance training that increases muscle mass and metabolic rate without overtaxing CFS patients.

* Add a focus on strengthening core abdominal muscles to relieve back pain and improve overall circulation.

* Advise patients who do not tolerate an upright position to use other positions rather than standing. Stretching and strengthening exercises can be performed on a floor mat or in water.

* Be aware that for patients who are severely deconditioned, it may be advisable to begin with a physical conditioning program, which is primarily anaerobic exercise, before introducing aerobic activities.

* Encourage patients who can tolerate greater levels of exercise to engage in movement therapies like yoga, tai chi, and qigong and light aerobic activity like short walks and swimming.

* Educate patients about the role that even modest strength-building exercise can play in increasing muscle mass and setting metabolic rate. Since many CFS patients have a very low metabolic rate, and metabolic syndrome is a common comorbid condition, building muscle mass is important.

Graded Activity and Exercise

Graded activity refers to movement and exercise that is started slowly and increased slowly, gradually increasing both the level of activity and the duration. Graded exercise may include both anaerobic and aerobic activities and can be effective in improving function and decreasing fatigue.[79,74] Functional capacity varies greatly from patient to patient, so exercise plans must be tailored accordingly.[80,81]

* Teach CFS patients that all exercise needs to be followed by a rest period at a 1:3 ratio, resting 3 minutes for each minute of exercise. Some patients can exercise for only short periods, just 2 to 5 minutes, without risking a relapse. This kind of interval activity -- exertion followed by rest -- can enable patients to gradually increase activity levels over a period of weeks or months.

* Advise deconditioned patients to limit themselves to the basic activities of daily living until they have stabilized. Several daily sessions of brief, low-impact activity can then be added, such as a few minutes of stretching, strength exercises, or light activity like walking or cycling. These sessions are increased by 1 to 5 minutes a week as tolerance develops.

* Instruct patients to return to the most recent manageable level of activity if they report that exercise is worsening symptoms.[76] Daily exercise may be divided into 2 or more sessions to avoid symptom flare-ups; some patients, however, cannot exercise daily early in the course of their rehabilitation.

* Advise patients to adapt their exercise program to allow maximum mat time. Alternating a short session of standing exercise with a short session of mat work may enable patients to tolerate more exercise without precipitating a crash.

* Encourage patients to consider aerobic activities they can do close to home, like walking for short intervals or swimming in a backyard pool. Going to the gym can involve showering, dressing, driving, and other exertion, exhausting a patient's energy envelope before aerobic activity even begins. And it may make some patients inadvertently overexert to "keep up with" other gym patrons.

* Write physical therapy referrals that are quite specific in outlining appropriate physical conditioning and graded exercise programs for CFS patients.

I'd like to hear what you all think of this. It certainly is a whole lot better than the SPARK! materials.

It is not a whole lot better; on the contrary, it is more of the same.. so much so that I don't even know where to begin and don't have the energy to even begin to address all the problems right now. I don't know why I or anyone else should have to, frankly. But basically...

I find this new CME disturbing in some of the same old ways... perhaps because much of it seems to be recycled material from their website or other literature. There's a bit more that is good, but much of that ends up contradicted or countermanded by parts that are bad (sound familiar?). In the section on pacing that precedes the sections quoted above, everything is fine; then they get to strength and conditioning, where the usual problem of lack of clarity begins - is this for all patients? THAT much activity.. for whom?? Note that they are essentially promoting low-level graded exercise there. Then they go on to promote GET - again!! What so many of us have been pushing for was to get rid of GET (and CBT) from CAA literature! Yet again, they claim it has been found to help with fatigue, exhaustion, whatever.. based on those same highly questionable studies; more on that later. This is the same kind of stuff from the SPARK material, stuck in the middle of a jelly donut.

Even more ridiculous: the bit quoted in other posts about 'activity phobia' such that 'some' lie around on couches.. Orla just attacked that point, and rightly so; it is something to SCREAM at the CAA about! There, and in the part about some patients inappropriately avoiding activity for fear of repercussions, they are continuing to spread the myth of hypochondriacal or 'symptom-exaggerating' or neurotic patients to our doctors; they are STILL spreading the damaging B.S. that is screwing a lot of people right now, including me.

Read through it again, if you hadn't noticed what I pointed out so far. It's the same old stuff - not as much of it, and with a few bonbons thrown our way, but the core problems remain. There is no way that an ME/CFS advocacy group should have found this suitable to disseminate to the medical community. I don't want to hear the cliche about throwing out the baby with the bathwater again - I have a better one: this is (should be) OUR literature and we can have our cake and eat it too. We don't need to settle for something inadequate or less. Significant sections of this new CME are just as confusing and potentially damaging as certain other attempts at decent information by the CAA; other bits of it - as pointed out by others - are simply shameful, and I hope fervently for my own sake that neither my current nor my future doctors ever see this. And if any of us have to be afraid that our doctors will see this, then what the heck good is it?

The CAA really needs our help. And they need to trust US, for whom they advocate, above all others.

 

[Lily]

Dr. Yes:

The CAA really needs our help. And they need to trust US, for whom they advocate, above all others.

I just don't see the CAA trusting us over Lucinda Bateman and Charles Lapp. Perhaps it would be possible to get Cheney, Peterson, Klimas and Bell to review and comment on this. I doubt they would criticize these two, but it would be interesting to see.