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The Role of Physiotherapy in Pre and Post Natal Women

Articles for health care professionals
The physical changes to a women’s body as related to pregnancy are multiple. The centre of mass changes, there is more pressure on the organs, and there is increased weight to be carried. All of this in a relatively short span of time often leads to back pain, pelvic pain and urinary incontinence. In fact, over two thirds of pregnant women experience back pain, one fifth experience pelvic pain and over 40% experience urinary incontinence in their first pregnancy – with half remaining incontinent at 8 weeks post-partum, and one third experiencing a new onset of incontinence after childbirth.
Evidence shows that group training programs designed and delivered by physiotherapists can relieve lower back pain, pelvic pain and urinary incontinence in pregnant women.
A randomized controlled trial by Morkved et al., of 289 pregnant women showed that 12 weeks of specially de-signed group training by a physiotherapist was effective in preventing lumbo-pelvic pain at 36 weeks of preg-nancy. The trial group participated in physiotherapist lead exercises 60 minutes a week from the 20th through the 36th week of pregnancy. There were significantly fewer women in the training group that reported lumbo-pelvic pain during pregnancy and after delivery.
A Cochrane review conducted in 2007 looked at interventions for preventing and treating back and pelvic pain in pregnant women, and found evidence for strengthening exercises, pelvic exercises, and water gymnastics reduc-ing lower back pain intensity better than standard prenatal care.
Another study by Morkved et al. of 301 pregnant women showed strong evidence for the prevention of urinary in-continence after a 12 week intensive pelvic floor muscle training supervised by physiotherapists at both 36 weeks of pregnancy and 3 months post-partum.
Harvey’s 2003 study of pregnant women showed that post-partum pelvic floor muscle training appeared to be ef-fective in decreasing post-partum urinary incontinence.
In 2005 the Canadian Physiotherapy Association and the Society of Obstetricians and Gynecologists of Canada issued a joint policy statement on Postural Health for Women and the Role of Physiotherapy. With respect to pregnant women, the joint policy statement recommends:
1. Physiotherapist directed pelvic floor muscle training to prevent urinary incontinence during pregnancy and after delivery.
2. Physiotherapist directed core stability training to prevent and treat back and pelvic pain during and following pregnancy.
While pre and post natal exercise programs are common, and they help many mothers, they may be harming oth-ers. An informal survey of a small number of these programs revealed;
– most lack even a basic screening, assessment or continued monitoring
– exercises were not adapted for any pain, posture or incontinence issues
– key factors such as the presence of a diastasis recti or caesarean section delivery were not addressed programs
– presented exercises that were contraindicated or not suitable for pregnant women in general
– there was no accommodation for the stage of pregnancy or post-partum status
– exercises presented in group class settings were the same for all participants, regardless of ability, stage of pregnancy and health status
How can a physiotherapist help pregnant women?
It is within the scope of practice of a physiotherapist to properly assess, treat and educate pregnant women in effective and safe exercises that have been shown to decrease back pain, pelvic pain and urinary incontinence – throughout their pregnancy and post-partum.
A good physiotherapist delivered program for pregnant women would;
1. Screen patients to ensure they could safely participate in an exercise program;
2. Assess patients for posture, strength, flexibility, balance as well as any musculoskeletal issues that could have a bearing on pregnancy;
3. Instruct patients on how to perform exercises safely and effectively;
4. Utilize an individualized approach – even in a group setting;
5. Enable group discussion and education regarding pre and post natal issues.
The goal of such a program would be to offer women improved prenatal fitness – that would lead to a healthier and easier pregnancy and delivery. A good program would also offer an integrated approach to health care – and share detailed assessment findings with the participant’s primary and pregnancy health care providers. As well, for women who are experiencing a high risk pregnancy, private sessions should be arranged with strict observa-tion of the health care provider’s restrictions with a focus on maintaining the pelvic floor and alleviating pain.
In researching this subject matter, this author discovered that the ideal program as described above – does not exist in our area. This program will be added to the authors personal practice. The program will be delivered in two parts
– one for pre natal mothers called ―Deliver Strong‖, and
– one for post natal mothers called ―Restore the Core‖.
Further program details will be sent to all Guelph area MD’s, but please feel free to contact the author directly through South City Physiotherapy of you would like more information.
I look forward to helping make sure that your pregnant patients are at their best for the birth of their baby.
Pre & Post Natal classes
References
Britnell, SJ et al. Postural health in women: The role of physiotherapy. Journal of Obstetrics and Gynaecology Canada 2005;27:493-510.
Harvey, MA. Pelvic floor exercises during and after pregnancy: A systematic review of their role in preventing pelvic floor dysfunction. Journal of Ob-stetrics and Gynaecology Canada, 2003;25:487-498.
Morkved S, Salvesen KA, Schei B, and Bo K. Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial. Acta Obstet Gynec 2007;86:276-282.
Morkved S, Bo K, Schei B, and Salvesen KA. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single-blind randomized controlled trial. Obstetrics & Gynecology 2003;101:313-319.
Nordahl K., Petersen C., Jeffreys R. Fit To Deliver: An Innovative Prenatal and Postpartum Fitness Program. Hartley and Marks Publishers Inc., 2005.
Pennick VE, YoungG. Interventions for preventing and treating pelvic and back pain in pregnancy (Review). Cochrane Database of Systematic Reviews 2007;(2):CD001139.
Stuge B, Gunvor H and Vollestad N. Physical therapy for pregnancy-related low back and pelvic pain: a systematic review. Acta Obstet Gynecol Scand 2003;82:993-990.

   Over a month ago
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Physical Rehabilitation: The Role of the Psychologist

Steve M. Shindell, Ph.D.

Steve M. Shindell, Ph.D. is in private practice at 1938 Peachtree Road NW, Suite 708, atlanta, GA 30309
As traditional psychotherapy modalities come under siege from insurance carriers, many psychologists are rediscovering practice areas that have long been the purview of psychology. One of these areas is rehabilitation psychology. It has been said that most disabilities are psychosocial problems with medical complications because of the severe changes that occur to a person's life post-disability. This article will discuss the various ways in which psychologists have been active in care of individuals with physical disabilities.
As a graduate student I tended to gravitate toward what I considered "emergency room" psychology rather than traditional mental health treatment. The patients I saw had tangible stresses and a relatively wary eye toward mental health practitioners. I found this work refreshing. The patients, by and large, rapidly became better psychologically. They were very apt to try new things, read books and, for the most part, eschew the victim role. In many ways, working within this field has made me more optimistic about people's coping skills. Also, working within a rehabilitation treatment team with physicians, nurses and rehabilitation therapists is wonderful for a psychologist. The psychologist tends to be the sole mental health practitioner. There are no ridiculous battles between psychiatry and psychology. Medical professionals see you as being solely responsible for your area, and for communicating this knowledge to the team.
Psychologists have been involved in physical rehabilitation for over 50 years for many reasons. Not the least of these reasons is that morbidity studies have shown that the best predictors of longevity following certain disabilities are psychological status, vocational attitudes and activity level. Interestingly, medical status was not a good predictor of longevity (Krause and Crewe, 1987). Thus, psychological interventions were not only important in producing quality of life changes they actually were the most important factors in improving length of life in persons with disabilities such as spinal cord injury.
This finding is not surprising in light of the fact that most disability care during the lifespan is focused on prevention of problems and remediation of behavioral problems such as depression , substance abuse, pain or cognitive deficits that could impair one's ability to adequately care for him/herself. Also, many social situations change after disability and learning appropriate responses to these situations is vital for their functioning. For example, learning how to deal with a bowel accident in public or how to ward off unsolicited help often is crucial in a person's successful rehabilitation.
Ironically, as payors have curtailed rehabilitation treatment by demanding shorter stays or less comprehensive treatment the role of the psychologist has grown. Many "difficult" patients who would be easily handled by a strong rehabilitation team are now discharged before the problem behavior is resolved. As a result, outpatient psychology treatment and rapid consultation services are needed. The psychologist who is in a position to offer such services can find a strong demand for his/her services.
Behavioral problems faced by individuals with disabilities fall into several categories.
"problem patient" behaviors which are generally identified as upsetting to the operation of a rehabilitation treatment team, such as substance abuse, pre-existing psychopathology or personality disorders;
"normal patient" behaviors which though not in and of themselves upsetting to a treatment team are seen as the psychologist's responsibility, such as adjustment problems, pain, depression, anxiety, sexuality and social skill training;
"good patient" behaviors not upsetting to the team but disruptive to the patient's ability to progress in rehabilitation treatment, such as passivity and dependency.

The psychologist's goal in inpatient rehabilitation is to rapidly assess the patient and offer brief action-oriented treatment to patients in order to aid the physical medicine team in best serving the patient. Patients with unrealistic goals, affective disorders, or secondary gains can delay or reduce their chances for successful completion of the rehab program. Therefore, it is crucial that there is an optimal match between the patient and treatment so that the patient does not become "stuck" in a portion of their program, or miss an integral part of their rehabilitation training before discharge.
In addition to my direct work with patients, I try to train the rehab team in basic psychological principles that they can apply to their work with patients. Many times these rehabilitation therapists (physical, occupational or speech therapists, or nurses) have little training in the emotional aspects of their work. By training them, I am providing valuable consultation to the team, and helping the team members to know when a referral for psychological treatment is most appropriate.
The following are some simple explanations of psychological principles that rehabilitation staff can use on a day to day basis.
1. Recognize that all behavior is purposeful. There is a reason why people act and react the way they do. Simply "wishing it was different" only tends to cause frustration and anger. The first step in any problem solving should include asking yourself, "What would make this person behave this way?" This questions leads to answers concerning irrational beliefs, inadequate coping styles, or a disparity in goals.
2. See disability as a social disease. Having a disability affects the way people interact with you, how their accomplishments or capacity for accomplishments are viewed. For better or worse the majority of people will be ignorant of their needs. After a disability a person is responsible for becoming a better communicator, to listen for unasked questions, and to take appropriate action. The individual with a disability becomes a member of a minority group, and every underprivileged group has to undergo prejudice, ignorance and injustices with either a smile, a sermon or a baseball bat. The person has the responsibility for deciding how to handle these injustices. Keep from seeing patients as people with disabilities but rather as unique people dealing with a process that is special and potentially frightening to them. Try to approach each visit as if it was a first time contact for you (as it is for them).

3. Recognize that disabilities are shared. People with disabilities may view family members differently. Their lives change; roles, attitudes and priorities change. Often the patient may not be the main problem, or the best solution may not always involve intervention with the patient. Family members may have unrealistic or conflicting expectations. Other economic or vocational pressures may be present. For example, patients with marginal disabilities such as partial vision loss or benign multiple sclerosis have the highest rates of seeking psychological help. One reason for this finding is that it is harder for these patients to find a place to belong or to find others who can identify with their disability. As a result, they may inappropriately deny their disability or accentuate the problems to "fit in better" with others who are more disabled.

4. Communicate that adaptation is forever. People do not finish adjusting to disability any more than they finish adjusting to growing up. Adaptation is a continuous process but it is also important to realize that the disability may not always be the main stress in a person's life. Professionals and family members tend to overestimate the severity and duration of depression secondary to a disability because of their own discomfort and wish to help.

5. See psychological rehabilitation as everyone's responsibility. All team members should teach the person how to interact effectively the with world as a part of physical rehabilitation treatment. Psychological issues should not be viewed as an obstacle to rehab treatment such as physical therapy exercises, but rather as part of the treatment itself.

6. Recognize adaptation as a unique, dynamic and complex process. There are many varieties of adaptation, but successful adaptation always involves four parts:A focus on abilities, not disabilities; realistic expectations of strengths and weaknesses; expression of a wide range of acceptable emotions; Integration of the disability in self-concept.

7. Act as an expert consultant. This role keeps you from assuming responsibility for your patient's successes and failures (a paternalistic attitude that keeps both sides unsatisfied). This allows you to continue to provide care within your expertise, and to debunk myths that your staff or patient has about his/her condition. It keeps the responsibility of change with the patient.

8. Reinforce positive behavior in your patients. Remember, you are part of your patients' world. Their behavior with you can be a microcosm of their behavior at home. Patients that are assertive with you probably will be assertive in everyday life, while passive patients take what you have to offer may not have the social skills necessary to get their needs met outside of the your office.

9. Don't impose your own values. Rather than looking at what a patient should be doing, look at what their goals are and how they might attained. Just because one coping style (for example, religion or Western medicine) works for you for other patients does not make it the only means of adaptation.

10. Don't assume that psychological defense mechanisms are always bad and best confronted directly. For example, people use denial to remain safe and to maintain their emotional homeostasis. Denial is a way of shutting off frightening information. Direct co

   Over a month ago
SEND

Physical Rehabilitation: The Role of the Psychologist

Steve M. Shindell, Ph.D.

Steve M. Shindell, Ph.D. is in private practice at 1938 Peachtree Road NW, Suite 708, atlanta, GA 30309
As traditional psychotherapy modalities come under siege from insurance carriers, many psychologists are rediscovering practice areas that have long been the purview of psychology. One of these areas is rehabilitation psychology. It has been said that most disabilities are psychosocial problems with medical complications because of the severe changes that occur to a person's life post-disability. This article will discuss the various ways in which psychologists have been active in care of individuals with physical disabilities.
As a graduate student I tended to gravitate toward what I considered "emergency room" psychology rather than traditional mental health treatment. The patients I saw had tangible stresses and a relatively wary eye toward mental health practitioners. I found this work refreshing. The patients, by and large, rapidly became better psychologically. They were very apt to try new things, read books and, for the most part, eschew the victim role. In many ways, working within this field has made me more optimistic about people's coping skills. Also, working within a rehabilitation treatment team with physicians, nurses and rehabilitation therapists is wonderful for a psychologist. The psychologist tends to be the sole mental health practitioner. There are no ridiculous battles between psychiatry and psychology. Medical professionals see you as being solely responsible for your area, and for communicating this knowledge to the team.
Psychologists have been involved in physical rehabilitation for over 50 years for many reasons. Not the least of these reasons is that morbidity studies have shown that the best predictors of longevity following certain disabilities are psychological status, vocational attitudes and activity level. Interestingly, medical status was not a good predictor of longevity (Krause and Crewe, 1987). Thus, psychological interventions were not only important in producing quality of life changes they actually were the most important factors in improving length of life in persons with disabilities such as spinal cord injury.
This finding is not surprising in light of the fact that most disability care during the lifespan is focused on prevention of problems and remediation of behavioral problems such as depression , substance abuse, pain or cognitive deficits that could impair one's ability to adequately care for him/herself. Also, many social situations change after disability and learning appropriate responses to these situations is vital for their functioning. For example, learning how to deal with a bowel accident in public or how to ward off unsolicited help often is crucial in a person's successful rehabilitation.
Ironically, as payors have curtailed rehabilitation treatment by demanding shorter stays or less comprehensive treatment the role of the psychologist has grown. Many "difficult" patients who would be easily handled by a strong rehabilitation team are now discharged before the problem behavior is resolved. As a result, outpatient psychology treatment and rapid consultation services are needed. The psychologist who is in a position to offer such services can find a strong demand for his/her services.
Behavioral problems faced by individuals with disabilities fall into several categories.
"problem patient" behaviors which are generally identified as upsetting to the operation of a rehabilitation treatment team, such as substance abuse, pre-existing psychopathology or personality disorders;
"normal patient" behaviors which though not in and of themselves upsetting to a treatment team are seen as the psychologist's responsibility, such as adjustment problems, pain, depression, anxiety, sexuality and social skill training;
"good patient" behaviors not upsetting to the team but disruptive to the patient's ability to progress in rehabilitation treatment, such as passivity and dependency.

The psychologist's goal in inpatient rehabilitation is to rapidly assess the patient and offer brief action-oriented treatment to patients in order to aid the physical medicine team in best serving the patient. Patients with unrealistic goals, affective disorders, or secondary gains can delay or reduce their chances for successful completion of the rehab program. Therefore, it is crucial that there is an optimal match between the patient and treatment so that the patient does not become "stuck" in a portion of their program, or miss an integral part of their rehabilitation training before discharge.
In addition to my direct work with patients, I try to train the rehab team in basic psychological principles that they can apply to their work with patients. Many times these rehabilitation therapists (physical, occupational or speech therapists, or nurses) have little training in the emotional aspects of their work. By training them, I am providing valuable consultation to the team, and helping the team members to know when a referral for psychological treatment is most appropriate.
The following are some simple explanations of psychological principles that rehabilitation staff can use on a day to day basis.
1. Recognize that all behavior is purposeful. There is a reason why people act and react the way they do. Simply "wishing it was different" only tends to cause frustration and anger. The first step in any problem solving should include asking yourself, "What would make this person behave this way?" This questions leads to answers concerning irrational beliefs, inadequate coping styles, or a disparity in goals.
2. See disability as a social disease. Having a disability affects the way people interact with you, how their accomplishments or capacity for accomplishments are viewed. For better or worse the majority of people will be ignorant of their needs. After a disability a person is responsible for becoming a better communicator, to listen for unasked questions, and to take appropriate action. The individual with a disability becomes a member of a minority group, and every underprivileged group has to undergo prejudice, ignorance and injustices with either a smile, a sermon or a baseball bat. The person has the responsibility for deciding how to handle these injustices. Keep from seeing patients as people with disabilities but rather as unique people dealing with a process that is special and potentially frightening to them. Try to approach each visit as if it was a first time contact for you (as it is for them).

3. Recognize that disabilities are shared. People with disabilities may view family members differently. Their lives change; roles, attitudes and priorities change. Often the patient may not be the main problem, or the best solution may not always involve intervention with the patient. Family members may have unrealistic or conflicting expectations. Other economic or vocational pressures may be present. For example, patients with marginal disabilities such as partial vision loss or benign multiple sclerosis have the highest rates of seeking psychological help. One reason for this finding is that it is harder for these patients to find a place to belong or to find others who can identify with their disability. As a result, they may inappropriately deny their disability or accentuate the problems to "fit in better" with others who are more disabled.

4. Communicate that adaptation is forever. People do not finish adjusting to disability any more than they finish adjusting to growing up. Adaptation is a continuous process but it is also important to realize that the disability may not always be the main stress in a person's life. Professionals and family members tend to overestimate the severity and duration of depression secondary to a disability because of their own discomfort and wish to help.

5. See psychological rehabilitation as everyone's responsibility. All team members should teach the person how to interact effectively the with world as a part of physical rehabilitation treatment. Psychological issues should not be viewed as an obstacle to rehab treatment such as physical therapy exercises, but rather as part of the treatment itself.

6. Recognize adaptation as a unique, dynamic and complex process. There are many varieties of adaptation, but successful adaptation always involves four parts:A focus on abilities, not disabilities; realistic expectations of strengths and weaknesses; expression of a wide range of acceptable emotions; Integration of the disability in self-concept.

7. Act as an expert consultant. This role keeps you from assuming responsibility for your patient's successes and failures (a paternalistic attitude that keeps both sides unsatisfied). This allows you to continue to provide care within your expertise, and to debunk myths that your staff or patient has about his/her condition. It keeps the responsibility of change with the patient.

8. Reinforce positive behavior in your patients. Remember, you are part of your patients' world. Their behavior with you can be a microcosm of their behavior at home. Patients that are assertive with you probably will be assertive in everyday life, while passive patients take what you have to offer may not have the social skills necessary to get their needs met outside of the your office.

9. Don't impose your own values. Rather than looking at what a patient should be doing, look at what their goals are and how they might attained. Just because one coping style (for example, religion or Western medicine) works for you for other patients does not make it the only means of adaptation.

10. Don't assume that psychological defense mechanisms are always bad and best confronted directly. For example, people use denial to remain safe and to maintain their emotional homeostasis. Denial is a way of shutting off frightening information. Direct co

   Over a month ago
SEND

What is PhysioYoga
PhysioYoga Therapy is a type of rehabilitation therapy that combines both evidence-based Physical Therapy and Medical Therapeutic Yoga resulting in a holistic approach to your treatment experience.

Physical Therapy (or Physiotherapy) is a well respected health care profession that uses evidence-based treatment methods to help clients restore and maintain optimal movement and function, as well as provide education on health maintenance and injury prevention. As licensed health care professionals, physical therapists have extensive training and knowledge about how the body functions. Specialized manual skills are used to assess, diagnose and treat a variety of injuries, disease symptoms and disabilities.

Medical Therapeutic Yoga (MTY) is used exclusively by licensed health care professionals who are trained to apply yoga principles and techniques to an individual with specific health concerns including acute or chronic illnesses or states of imbalance. MTY provides a safe and effective approach to healing, using a biopsychosocialspiritual approach that promotes self efficacy, empowerment and self healing.

Yoga is an ancient life system of health that promotes ‘union’ and connects body, mind, breath and spirit as one unit, therefore enhancing and promoting an overall balanced lifestyle of health and well-being.

The Benefits Of PhysioYoga
When practiced regularly, the benefits are numerous. Physically, it may result in: improvement in muscular strength, endurance, flexibility, body awareness, circulation, digestion, hormonal balance, respiration, immune function, bone strength, normalizing blood pressure, reduction or normalization of body weight, reduction of pain, improved self management of pain and improved ability to self regulate. Mentally, improvements in alertness, concentration and sleep patterns may be experienced as well as reduction in stress and anxiety and improvements in your ability to relax. The key benefit is an overall state of health and well-being.

Some of the common conditions addressed are:

Back and neck pain, musculoskeletal injuries (shoulders, hips, knees, etc), chronic or persistent pain, osteoarthritis, osteoporosis, diabetes, fibromyalgia, high blood pressure, Irritable Bowel Syndrome, migraines/headaches, pregnancy, anxiety, rheumatoid arthritis, scoliosis, urinary stress or urge incontinence. It is worthy to note the role PhysioYoga plays in injury prevention and overall health and wellness!

“…you really treat the whole body instead of just attacking the “problem area” – resulting in approaching the process in a much more positive way – of turning my body into an instrument I can use as opposed to something broken to be fixed” A.P.
“….you taught me that it’s never one spot you need to work on, but everything as a whole; that breathing is essential, and less can be more; and that the state of mind is just as important as anything physical I do. My attitude towards self care has changed and I also learned that every effort I make, even if small, is worthy.” S.H.

   Over a month ago
SEND

What is PhysioYoga
PhysioYoga Therapy is a type of rehabilitation therapy that combines both evidence-based Physical Therapy and Medical Therapeutic Yoga resulting in a holistic approach to your treatment experience.

Physical Therapy (or Physiotherapy) is a well respected health care profession that uses evidence-based treatment methods to help clients restore and maintain optimal movement and function, as well as provide education on health maintenance and injury prevention. As licensed health care professionals, physical therapists have extensive training and knowledge about how the body functions. Specialized manual skills are used to assess, diagnose and treat a variety of injuries, disease symptoms and disabilities.

Medical Therapeutic Yoga (MTY) is used exclusively by licensed health care professionals who are trained to apply yoga principles and techniques to an individual with specific health concerns including acute or chronic illnesses or states of imbalance. MTY provides a safe and effective approach to healing, using a biopsychosocialspiritual approach that promotes self efficacy, empowerment and self healing.

Yoga is an ancient life system of health that promotes ‘union’ and connects body, mind, breath and spirit as one unit, therefore enhancing and promoting an overall balanced lifestyle of health and well-being.

The Benefits Of PhysioYoga
When practiced regularly, the benefits are numerous. Physically, it may result in: improvement in muscular strength, endurance, flexibility, body awareness, circulation, digestion, hormonal balance, respiration, immune function, bone strength, normalizing blood pressure, reduction or normalization of body weight, reduction of pain, improved self management of pain and improved ability to self regulate. Mentally, improvements in alertness, concentration and sleep patterns may be experienced as well as reduction in stress and anxiety and improvements in your ability to relax. The key benefit is an overall state of health and well-being.

Some of the common conditions addressed are:

Back and neck pain, musculoskeletal injuries (shoulders, hips, knees, etc), chronic or persistent pain, osteoarthritis, osteoporosis, diabetes, fibromyalgia, high blood pressure, Irritable Bowel Syndrome, migraines/headaches, pregnancy, anxiety, rheumatoid arthritis, scoliosis, urinary stress or urge incontinence. It is worthy to note the role PhysioYoga plays in injury prevention and overall health and wellness!

“…you really treat the whole body instead of just attacking the “problem area” – resulting in approaching the process in a much more positive way – of turning my body into an instrument I can use as opposed to something broken to be fixed” A.P.
“….you taught me that it’s never one spot you need to work on, but everything as a whole; that breathing is essential, and less can be more; and that the state of mind is just as important as anything physical I do. My attitude towards self care has changed and I also learned that every effort I make, even if small, is worthy.” S.H.

   Over a month ago
SEND