Curovate

A blog about everything related to physical therapy, rehabilitation, ACL injury, ACL surgery and recovery!

How do I cure jumpers knee? Or decline squats for patellar tendinopathy

What is Patellar Tendinopathy?
The patella, also known as the kneecap, is connected to the lower leg by a stringy structure called the patella tendon.
Jumper's knee, also known as patellar tendinopathy, is an injury where the patellar tendon gets overworked due to too much stress over time.1 The patellar tendon is put under a lot of stress when jumping, landing, starting, and stopping. When these activities are done too often with a lot of force, the patellar tendon begins to change its structure in a way that causes pain.1 If you want to read more about jumpers knee refer to our previous blog here.

Evidence For Decline Squats
Many studies have shown that lowering yourself down during a squat (called an eccentric movement) on a decline surface is effective for treating patellar tendinopathy. This is likely because for the same amount of work, there is more loading on the patellar tendon, compared to the thigh muscles, when in the decline position2. As long as the decline squat is completed in a controlled manner and not over-done, loading the tendon improves its function.3

Regular Squats vs Decline Squats: One study that looked at regular squats vs. decline squats in 17 patients found that decline squat training caused less pain and lead to a faster return to full function in daily life compared to regular squats.4

One-legged Decline Squats vs One-legged Step Squats: A one-legged step squat is where the back leg is elevated on a step and the front leg is lowering the body. A study completed on 17 volleyball players found that one-legged decline squats were more effective than one-legged step squats for improving pain and the players score on a knee function test after 12 months.5

Horizontal Surface vs Decline Surface: One study completed on 13 people showed that eccentric squats on a decline board worked the patellar tendon 20-25% more than eccentric squats on a flat surface.6 This demonstrates that a decline surface is better at strengthening the patellar tendon.

Protocol For Decline Squat Program or how many and how often should I do decline squats:
One study that researched the best guidelines for treating patellar tendionpathy found that decline squats must be included in the program to help patellar tendinopathy.3 The researchers suggested decline squats should be done twice a day for 3 sets of 15 repetitions based on the results they gathered from 7 other research papers.3 The article found that adding resistance slowly over time helps improve the patellar tendon's function as long as the exercise is done with control, and not done excessively.3

Our next blog post will be a video on how exactly to do decline squats at home with instructions on how to progress.

References

Jumpers knee - what is it and how can I avoid it?

Let's first explain what a tendon is. A tendon is a strong band like structure made of fibrous tissue called collagen that connects muscle to bone. It has the responsibility of transmitting force from muscle to bone. The patellar tendon connects the bottom of the knee cap (patella) to the shin bone (tibia).1 The patellar tendon can develop small partial tears or complete tears from intense physical activity.1 If the patellar tendon has weakened over time due to activity and improper strengthening then it can be more likely to tear. Now, what exactly is tendinopathy of this tendon? This is what most people call jumpers knee.

Patellar tendinopathy is a common overuse injury that results in a slow increase in pain at the patellar tendon over time. At first, patellar tendinopathy was thought to be inflammation (redness, swelling and pain caused by an injury) of the patellar tendon but further research has indicated that patellar tendinopathy is actually degeneration or wearing away within the tendon.2 That is, the collagen fibers that make up a tendon change in structure and weaken. This happens with overuse which leads to continual micro (very small) tears of the patellar tendon. Having a gruelling training schedule and not allowing enough time of rest can disturb healing of the tendon. Therefore, degeneration of the collagen fibers occurs.2 Patellar tendinopathy is diagnosed as dysfunction and pain associated with the patellar tendon and is often called "jumper's knee."3 This is because activities like jumping produce a large load on the patellar tendon, which if not done properly can overload the tendon. We have a great blog on proper jumping and landing mechanics here. The pain is often just under the knee cap on the upper part of the tendon.

Furthermore, studies have shown people between the ages of 13 to 19 are more likely to get jumper's knee, especially if they are elite athletes.3 Some sports in particular show higher rates of jumper's knee. For example, from a study conducted in the Netherlands, the highest rates of jumper's knee were in recreational and elite volleyball players (14.4%) and lowest rates were for soccer players (2.5%).3

How this condition occurs exactly is still being researched; but there are risk factors related to training habits and personal characteristics that can lead to jumpers knee. The more often an athlete trains per week, the longer the athlete trains for per session and the less rest per session and between sessions increases the chances of developing jumpers knee. Personal factors include: height, weight, alignment of the legs, and strength of the quadriceps (front of the thigh) and hamstrings (back of the thigh) muscles.3

This blog focused on what jumpers knee is and how to avoid it. Our next blog post will tell you what you can do if you already have jumpers knee.

References

Why is it taking me so long to get better after ACL surgery?

There are many factors that contribute to how a person will recover after ACL surgery. The 4 major factors for recovery are listed below. The first 2 are things you can control or work on to improve your recovery. The last 2 are factors that you do not have control over.

1. Ability to bend the knee fully before surgery
A study that looked at factors affecting recovery after ACL surgery found that people who were able to bend their knee all the way before surgery had faster recoveries than those who could not bend their knee all the way.1 Fortunately, physiotherapy treatment can help improve your ability to bend your knee before and after surgery. Our app Curovate can also help your ability to bend your knee.

2. Strength of muscles around the knee
The strength of the muscles that move the knee can predict how long it will take to recover. The faster the injured knee regains strength equal to the unaffected knee after surgery, the better the outcome is 1 year later.2 It is especially important to regain strength in the hamstring muscles (at the back of the thigh that help bend the knee). Weak hamstring muscles increases the risk of re-injuring the ACL.3 The exercises in our app Curovate can help you regain your strength.

3. Age
You may have heard before that young people heal much faster than older people. This happens to be the case when it comes to ACL surgery and getting back to all of your activities. Surgery is sometimes avoided in older people because of a higher complication rate compared to younger people.4 A study on 104 patients that underwent ACL surgery found that 12 months after ACL surgery, patients who were 20 years old or younger needed less rehabilitation time than patients over 20 years old. The younger patients had less pain, less swelling, better mobility, and strength and returned back to their normal level faster.5

4. Other injured structures in the knee
There are 4 major ligaments that stabilize the knee: ACL, PCL, MCL, and LCL. The ACL can be injured alone but in more severe injuries, other structures can be torn as well. One study showed the patients who had torn multiple ligaments had a longer recovery time compared to just tearing their ACL alone.5 This is because multiple ligament injuries might require more procedures, have more pain and symptoms, and also require more time before the patient can move after surgery.5

Other common factors that have been studied with regards to how a person will recover from ACL surgery include gender, body mass index (BMI - a ratio of height to weight), and type of ACL graft used. These factors do not have a strong influence on the rate of recovery.6

References

Physical therapy advice after knee surgery to keep up with your exercises! – Part 3

Struggling with motivation to keep up with your exercises at home? Look no further!

Previously we discussed some of the reasons why people find it challenging to do their rehabilitation exercises. We looked at how fear and pain (Part 1) or a lack of time and equipment (Part 2) can affect a person’s willingness to do their exercises to recover after injury or surgery.

Staying motivated and enjoying your rehabilitation program is critical to recovery. I will discuss how these two factors effect a patient’s commitment toward their rehabilitation and include tips from our physical therapist to help you along the way.

Motivation

Motivation is having the desire to do something.1 We tend to do things because it is personally rewarding to us, or for an external reward like money or a trophy. In the case of exercising at home after injury or surgery, motivation is a huge factor that determines your success. Some people need an outside influence to maintain and/or increase their motivation, such as the presence of their physical therapist or other health care provider.2 For this reason, a lack of self-motivation is a barrier to completing exercises on their own.

Some people have higher levels of intrinsic motivation, which can be thought of as being “self-motivated,” and are more likely to complete their home exercises.3 The more motivation you have on your own, the more likely you will do your exercises at home without your physical therapist and increase your chances of a successful recovery.

Physical therapy advice - After reading the section above many of you might be thinking, "I am not one of those self-motivated people! What can I do?" Here are some tips I have learned from working with patients over the past 17 years and brilliant suggestions from my patients who have figured out the key to their own personal motivation:

  • Set an achievable goal! If you love soccer and you want to get back to playing let that be your long term goal after injury or surgery. In rare cases returning to sports is not recommended after injury or surgery but this can be discussed with your health care provider.
  • Find other people who have gone through the same thing and talk to them about their journey. This can be done face to face but more and more people are finding this community and support on-line. One of these examples is the ACL Recovery Club which is an on-line community for people after ACL injury or surgery. It helps to know others have gone through the same challenges and have had successful recoveries.
  • Give your self real or virtual rewards! Yes it sounds odd but even virtual rewards that are meaningful to you can make you more motivated. We have a simple system of stars and trophies within our ACL app that helps people stay motivated to do their daily exercises. Research has shown that even virtual rewards are effective to motivate people.
  • Track your progress! It is hard to be excited about knee movements or being able to lift your leg without pain but these will be some of your initial goals after surgery. Having a method to track your progress either on a piece of paper, a chart or an on-line or app tracker will keep you motivated. When you use our ACL app it tracks all of your progress daily for your exercises, knee movements, and achieved goals without ever having to write anything down. The easier it is to track your progress the more likely you will be to continue doing it!
Lack of enjoyment

When it comes to completing your rehabilitation exercises there may be times where you feel like you would rather be doing something else, especially if you are doing your exercises at home by yourself. After an ACL injury, most of the exercises given to patients by their physical therapist are low-intensity and may not be very exciting depending on the stage of recovery. Some people report that the exercises they do are “boring, mundane, and a waste of time,”2 and this discourages them from following their rehabilitation program. In order to commit to your rehabilitation program, it is important that you enjoy what you are doing, especially since recovery takes months and not days.

Physical therapy advice - This is a tough area to advise patients since I can't make anyone love their exercises. Here are some tips that can help:

  • Pair your exercises with an activity that you love. You can do your exercises while watching your favourite show, listening to some great music or a podcast or watching a sporting event on tv.
  • Make sure that you have a long term goal that will make the exercises that you are doing have some purpose and meaning. It is hard to enjoy leg raises but if you know that this will let you be more independent in walking and eventually jogging this might lead to you enjoying your exercises. In our ACL app jogging starts at 3 months!
  • Look into the future! It is important to remember why you are doing your exercises. Look at the later stages of your rehabilitation and this might get you excited about what you can do in a month or 3 months. Our ACL app provides you with weekly goals on the "Journey" page and this feature allows you to look at your goals currently but also throughout the entire rehabilitation process.
  • Do your exercises in a place that you love. Some people love the gym and some people love their living room. I encourage these people to workout in that space so that they feel better about what they are doing. Even if this means going to the gym to do knee bending exercises.

Remember this process is hard but the exercises have been designed to allow you to return to all of those activities that you love.

References

What kind of exercises and sports can I do after a knee replacement?

If you have had or are going to have a knee replacement, then you have probably wondered about what kind of exercises and sports you will be able to do when you have recovered.

It is important to begin a knee replacement rehabilitation program as soon as possible after surgery. The faster your operated leg regains its strength and flexibility, the more likely you will be to see improvements in your independence and with activities of daily life.1

At 13 to 16 weeks after knee replacement surgery, it would be a good time to begin some endurance activities but there are some requirements before you start:

  1. You must have minimal to no pain in your knee.
  2. You must have minimal to no swelling in your knee.
  3. You must be able to bend and straighten your leg almost as well as your non-operated leg.
  4. You must be able to walk fast without walking aids (walker or cane) or limping.
  5. You must be able to walk for 20 minutes without experiencing pain or swelling.

Speak to your healthcare provider before beginning any new exercises, especially if you are not sure if you meet the five requirements listed above.

The charts below provides recommendations for patients following knee replacement 13-16 weeks AFTER surgery. These charts have been adapted from a clinical commentary released by the Journal of Orthopaedic and Sports Physical Therapy in 2008. A clinical commentary is written by a group of clinical experts when there is no definitive answer provided by research. This means that there isn't a study that says "golf is safe after 16 weeks." So a group of experts decided this based on what they know and the research that is available.

Our physical therapist, Nirtal Shah, states: "Some of these activities may be possible before 13 weeks such as stationary biking, others around 13 weeks such as swimming and some may take 8-12 months such as golf, skiing and doubles tennis. This is a guideline and should be used with the guidance of a healthcare provider."

Recommended Activities
Swimming Golf
Biking (stationary) Walking
Dancing (ballroom, jazz, square) Horseback riding
Bowling Croquet
Horseshoes Aerobic (low impact)
Shooting Shuffleboard


Activities Recommended with Previous Experience
Biking (road) Canoeing
Hiking Speed walking
Skiing (stationary, cross country) Rowing
Tennis (doubles) Weight machines


Activities Not Recommended
Racquetball Squash
Rock climbing Soccer
Singles tennis Volleyball
Handball Football
Gymnastics Lacrosse
Hockey Basketball
Jogging


No Conclusion
Fencing Rollerblading/inline skating
Downhill skiing Weightlifting



It is important to remember that your recovery from surgery should be a slow and steady process. Doing your rehabilitation exercises everyday will allow you to be more mobile as you recover and get you back to doing the activities you love!

References

6 Things You Need to Know After Knee Replacement

1. Pain management:

There will be pain in your knee and leg after having a total knee replacement. It is very important to begin your rehabilitation as soon as possible after surgery but pain can make moving your leg almost impossible! That is why taking the proper dosages of your pain medication is necessary for your comfort and recovery.1

2. Avoid infection:

Undergoing any kind of surgery has a risk of infection. Out of 6489 patients with total knee replacements, 116 of them experienced infection. That means only 1.7% of these patients developed an infection.2 Making sure your wound is kept clean and dry and that your medication dose after surgery includes antibiotics can help you avoid infection.3

3. Avoid blood clots:

In a study of 517 patients with total knee replacements, only 14% of the 468 patients taking preventative medication experienced blood clots. Although, in the 49 patients who did not take this medication, 84% of them experienced blood clots.4 Therefore, it is very important that you are taking the appropriate medications to lower your risk of getting a blood clot.

4. Swelling management:

After knee replacement, it is important to use the PRICE method3 to reduce swelling in your operated leg and aid in reducing your chances of experiencing a blood clot. The PRICE method includes:

I. Protection - After surgery, you will be given a "weight bearing restriction." This means how much weight you are allowed to put on your leg after surgery. Reduce the risk of further injury by putting only the amount of weight on your leg as you have been instructed. You will also be given some form of assistive device (like a walker or a cane) early on to help unload the surgical leg.5

II. Resting - Allowing for your operated leg to heal by avoiding stressful activity but still doing required exercises.

III. Icing - Use of cold treatments to reduce pain and swelling. First, protect your skin from direct contact with the ice and make sure the wound stays dry. This can be done by placing a plastic bag over the scar before you ice your knee. Then cycle the cold treatment, 20 minutes on followed by 40 minutes off.

IV. Compression - Use of an elastic bandage to minimize swelling and provide some support. For further information and instruction on how to wrap an elastic bandage check out our previous blog here.

V. Elevation - Decrease swelling and pain in your knee by positioning your operated leg above the level of your heart. Putting a thick cushion or pillows under your leg while laying down is a good way to do this. However, make sure when you are elevating your knee to keep it straight and not bent.

5. Get moving:

As soon as you are able to, start moving the toes of your operated leg. Continuously moving your toes and ankles for 2 minutes, 3 times an hour is a great start! It is important to start your rehabilitation program in order to limit stiffness.2,6

6. Rest:

Although it is important to move your operated leg, it is also important that your body rests. Giving your body time to rest and recover at a comfortable pace while doing required rehabilitation after surgery is one of the best things you can do!

Total knee replacement surgery is...

A surgery that replaces up to three parts of the knee joint with implants. These implants are made of metals and hard plastics. This kind of surgery is usually done to help with pain and mobility issues due to osteoarthritis in the knee.7

Just like we have an app for ACL rehabilitation, Curovate is in the process of developing an app for patients after a total knee replacement surgery! If you have any questions, suggestions or wish to be one of the first people to test our app please email us at meetcura@gmail.com

References

More than ACL rehabilitation. Any questions?

Since I started this blog on December 11th, 2016 with my first blog about how to use crutches I have been focused on ACL rehabilitation. This made sense since I have helped to create an app for ACL injuries! For 3 reasons the blog will now include more than just ACL topics: 1. My patients and our blog users have been asking questions about things related to physical therapy and rehabilitation for other injuries, 2. I work with patients who have other injuries, 3. the excellent blog contributors I work with (Alenna, Nicole, Prateek, Tashkin) have expertise in a variety of areas besides ACL injuries.

This blog will still include information about ACL injuries but it will also include information about rehabilitation for other injuries.

I am now asking anyone who has a question related to physical therapy, rehabilitation or injury to email me (meetcura@gmail.com) with your question. If it is a really good questions that could help others we will answer the question in a future blog and publish your name! On the other hand if you are a physical therapist or an expert in the area of injury prevention or rehabilitation and you wish to contribute to our blog please email us (meetcura@gmail.com) and let us know what you wish to blog about.

Do knee braces work? What does the research say?

What is a knee brace?

Knee braces are external devices which can be soft or rigid and are prescribed by some healthcare providers after knee injury or surgery. In this blog I will focus on knee braces prescribed after an anterior cruciate ligament (ACL) surgery.

How is a knee brace used? Are there any issues with bracing?

Knee braces are recommended by some healthcare providers for one to two months after an Anterior Cruciate Ligament (ACL) surgery1. According to a survey done on American Orthopaedic surgeons, 63% report prescribing functional bracing after ACL surgery. Additionally, 71% of them prescribe these braces for up to 1 year after surgery2.

What are the different types of braces for the knee?

There are two kinds of braces used after ACL surgery:

  1. Functional knee braces - are worn after an ACL surgery to reduce improper knee movements such as excessive rotation, sliding side to side or front to back (translation) and the knee caving inwards.3 They are designed to substitute for damaged ligaments and are often prescribed for people who have torn their ACL and are not planning to get surgery.4

  2. Prophylactic knee braces - are designed to protect people from sustaining a knee injury without causing limitations in knee movement.5

What does research say?

Researchers found that people under the age of 30 experience muscle weakness with long term use of braces (1 to 2 years), compared to short term uses (3 months).6

Prophylactic Knee brace Functional Knee brace
1. There was no significant difference found among 31 healthy college athletes in single leg vertical jump, cross-over hop, and average power between wearing a prophylactic brace and not wearing a brace. Average power output was measured using isokinetic testing. Isokinetic testing involves a piece of equipment that allows the knee to be resistance tested while the person bends and straightens their knee at a specific speed. The speeds used were 60, 180 and 300 degrees per second.5 1. Researchers found a substantial reduction in quadriceps muscle (muscles at the front of your thigh) strength with long term use (1-2 years). There were no differences in the amount of knee movement (range of motion) and a persons awareness of their knee position (proprioception). Researchers did find wearing a brace improved knee stability by reducing excessive lower leg rotation and translation, as well as decreasing excessive knee bending or straightening. This study was a literature search of 15 research articles using PubMed and Embase databases to compare functional bracing to no bracing 3 months after ACL reconstruction.3
2. There are no significant differences in the amount of pressure and force on the knee between wearing a prophylactic brace or not. But wearing the brace significantly reduced rotation (inward and outward rotation) of the knee. For example, lower leg rotation reduced from 19.76 degrees to 15.91 degrees, when wearing the brace. Additionally, participants found that wearing the brace gave them a sense of stability while running. This study tested 20 female netball university athletes (20 years old) who were asked to do running, jumping and cutting movements on a force plate in a lab.7 2. 100 patients, all with a torn ACL, underwent a Bone-Patellar-Bone ACL reconstruction and were randomized into a braced and non-braced group. They were followed for 12 months. Patients in the unbraced group returned to work 1.84 months after surgery, compared to 2.28 months in the braced group. Additionally, 96% of the unbraced patients said they have no difficulty in climbing stairs compared to 93% of patients who used a functional brace.8


Do you need some more information and assistance after your ACL injury? Check out our ACL app!

References

  1. Hiemstra, L. A., Veale, K., & Sasyniuk, T. (2006). Knee immobilization in the immediate post-operative period following ACL reconstruction: A survey of practice patterns of canadian orthopedic surgeons. Clinical Journal of Sport Medicine, 16(3), 199-202.

  2. Marx, R. G., Jones, E. C., Angel, M., Wickiewicz, T. L., & Warren, R. F. (2003). Beliefs and attitudes of members of the american academy of orthopaedic surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 19(7), 762-770

  3. Lowe, W. R., Warth, R. J., Davis, E. P., & Bailey, L. (2017). Functional bracing after anterior cruciate ligament reconstruction: A systematic review. Journal of the American Academy of Orthopaedic Surgeons, 25(3), 239-249.

  4. Cluet, J. (2017). Types of Knee Braces for Support and Injury Prevention. VeryWell.

  5. Mortaza, N., Ebrahimi, I., Ali, A. J., Abdollah, V., Kamali, M., Wan Abu Bakar, W. A., & Noor Azuan, A. O. (2012). The effects of a prophylactic knee brace and two neoprene knee sleeves on the performance of healthy athletes: A crossover randomized controlled trial. PLoS One, 7(11), e50110.

  6. Risberg, M. A., Beynnon, B. D., Peura, G. D., & Uh, B. S. (1999). Proprioception after anterior cruciate ligament reconstruction with and without bracing. Knee Surgery, Sports Traumatology, Arthroscopy, 7(5), 303-309.

  7. Sinclair, J. K., Vincent, H., & Richards, J. D. (2017). Effects of prophylactic knee bracing on knee joint kinetics and kinematics during netball specific movements. Physical Therapy in Sport, 23, 93-98.

  8. Nazem, K. A., Mehrbod, M., Borjian, A., & Sadeghian, H. (2006). Anterior cruciate ligament reconstruction with or without bracing.

Physical therapy advice after knee surgery to keep up with your exercises! – Part 2

In my last post I discussed how fear and pain make it challenging to do your exercises after knee surgery (see Part 1 here). In this blog, we outline two more reasons why people struggle with their rehabilitation exercises after surgery. We also include physical therapy advice to help you overcome these barriers.

Perceived lack of time

Let’s face it; we live in a fast paced society with many personal and professional commitments. These commitments take a toll on the amount of available time for attending physical therapy appointments and doing daily exercises at home. When it comes to doing the things you need to do to recover, a busy daily routine and a perceived lack of time are significant barriers.1 When people were asked after surgery about why they find it difficult to complete their exercises at home, they mentioned work, holidays, family and social commitments all tend to take precedence over their exercises.1

Physical therapy advice - Recovery after ACL surgery is a huge time commitment for 8-12 months. After surgery is when all of the hard work starts. In the first month after surgery, rehabilitation can take 3-4 hours per day. In the later stages it can take at least 1 hour per day. Keeping an agenda (either on paper or electronic) is a great tool to keep track of all your responsibilities! Make your appointments or at-home exercise sessions a priority by scheduling a block of time during your day, as you would your other important life events! Here are some tips to help:

  • Do your exercises at the same time every day
  • If there is equipment you need have it in an easy to access place
  • Seeing your list of exercises either on a piece of paper or electronically is a very helpful reminder for you to do your exercises. If you haven't already, try our ACL app to help you do your daily exercises.
  • Ask friends and family to remind you to do your exercises or to check in on you every few days or weeks
  • If you know people who have gone though the same surgery ask their advice or exercise with them
  • Set reminders on your phone to do your daily exercises
  • Most importantly make time for these crucial exercises so that you can return back to your normal physical activity and daily activities.
Lack of availability of equipment

Doing your home exercises often requires some sort of equipment such as exercise bands, light dumbbells, or an exercise ball. When attending physical therapy appointments at a clinic all the necessary equipment is provided and completing the exercises is not an issue. However, when patients are given exercises that require the use of equipment at home, some patients report not having access to the appropriate equipment.1 As a result, instead of independently completing the exercises, patients opt to wait until they go to see their physical therapist. If you do not have access to the equipment necessary for the exercises given to you by your physical therapist, be sure to tell them so they are able to prescribe exercises that you can do at home.

Physical therapy advice - There is always an alternative that can be provided for most equipment that you do not have at home. You do not have to have access to a gym or any fancy equipment to recover fully after surgery. Ask your physical therapist how you can modify exercises that require equipment. Almost all of the exercises in our ACL app can be done with no special equipment. Here are some simple examples of things that can be substituted for equipment:

  • A folded pillow or couch cushion can be used as a balance disc or balance board for balance exercises
  • A water bottle filled with water or sand or rocks can be used as a weight
  • A few books can be used to replace a step for step up and down exercises
  • A water bottle can be used as a pylon for running drills, clock lunges and squat touch down exercises. All of these exercises are included in our app.
  • An office chair with wheels can be used as an exercise ball
  • Resistance bands (which can cost $5-15 per band) are a cheap alternative to using cable machines found in gyms and other forms of resistance equipment that you may not have

References