This study investigated whether the findings on the scans of the lumbar spine that had been made in 1989 predicted the development of low-back pain in a group of 67 asymptomatic individuals with no history of back pain. In 1989, 21 subjects (31%) had an identifiable abnormality of a disc or of the spinal canal.
A questionnaire concerning the development and duration of low-back pain over a 7 year period was sent to the 67 asymptomatic individuals from the 1989 study. A total of 50 subjects completed and returned the questionnaire. A repeat magnetic resonance scan was made for 31 of these subjects.
Of the 50 subjects who returned the questionnaire, 29 (58%) had no back pain. Low-back pain developed in 21 subjects during the 7 year study period. The 1989 scans of these subjects demonstrated normal findings in twelve, a herniated disc in five, stenosis in three, and moderate disc degeneration in one. Eight individuals had radiating leg pain; four of them had had normal findings on the original scans, two had had spinal stenosis, one had had a disc protrusion, and one had had a disc extrusion. In general, repeat magnetic resonance imaging scans revealed a greater frequency of disc herniation, bulging, degeneration, and spinal stenosis than did the original scans.
The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original 1989 scans. Clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.
Source: http://thepainsource.com/archives/399
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
Tuesday, August 31, 2010
Thursday, August 19, 2010
Save Your Knees
Land on your toes, save your knees
August 10, 2010
Aggie player Paige Mintun goes for a layup and will be landing on those toes. (Wayne Tilcock/Davis Enterprise photo)
Anterior cruciate ligament injuries are a common and debilitating problem, especially for female athletes. A new study from UC Davis shows that changes in training can reduce shear forces on knee joints and could help cut the risk of developing ACL tears. The research was published online Aug. 3 in the Journal of Biomechanics.
"We focused on an easy intervention, and we were amazed that we could reduce shear load in 100 percent of the volunteers," said David Hawkins, professor of neurobiology, physiology and behavior at UC Davis. Hawkins conducted the study at the UC Davis Human Performance Laboratory with graduate student Casey Myers.
The anterior cruciate ligament lies in the middle of the knee and provides stability to the joint. Most ACL injuries do not involve a collision between players or a noticeably bad landing, said Sandy Simpson, UC Davis women's basketball coach.
"It almost always happens coming down from a rebound, catching a pass or on a jump-stop lay-up," Simpson said. "It doesn't have to be a big jump."
Hawkins and Myers worked with 14 female basketball players from UC Davis and local high schools. They fitted them with instruments and used digital cameras to measure their movements and muscle activity, and calculated the forces acting on their knee joints as they practiced a jump-stop movement, similar to a basketball drill.
First, they recorded the athletes making their normal movement. Then they instructed them in a modified technique: Jumping higher to land more steeply; landing on their toes; and bending their knees more deeply before taking off again.
After learning the new technique, all 14 volunteers were able to reduce the force passed up to the knee joint through the leg bone (the tibial shear force) by an average of 56 percent. At the same time, the athletes in the study actually jumped an inch higher than before, without losing speed.
Hawkins recommends warm-ups that exercise the knee and focusing on landing on the toes and balls of the feet. The study does not definitively prove that these techniques will reduce ACL injuries, Hawkins said: that would require a full clinical trial and follow-up. But the anecdotal evidence suggests that high tibial shear forces are associated with blown knees.
Hawkins and Myers shared their findings with Simpson and other UC Davis women’s basketball and soccer coaches, as well as with local youth soccer coaches.
Simpson said that the team had tried implementing some changes during last year's preseason, but had found it difficult to continue the focus once the full regular season began. In live play, athletes quickly slip back to learned habits and "muscle memory" takes over, he noted. More intensive off-court training and practice would be needed to change those habits, he said.
"We will be talking about this again this season," Simpson said. Implementing the techniques in youth leagues, while children are still learning how to move, might have the most impact, he said.
About UC Davis
For more than 100 years, UC Davis has engaged in teaching, research and public service that matter to California and transform the world. Located close to the state capital, UC Davis has 32,000 students, an annual research budget that exceeds $600 million, a comprehensive health system and 13 specialized research centers. The university offers interdisciplinary graduate study and more than 100 undergraduate majors in four colleges — Agricultural and Environmental Sciences, Biological Sciences, Engineering, and Letters and Science. It also houses six professional schools — Education, Law, Management, Medicine, Veterinary Medicine and the Betty Irene Moore School of Nursing.
Media contact(s):
•David Hawkins, Neurobiology, Physiology and Behavior, (530) 752-2748, dahawkins@ucdavis.edu
•Mike Robles, Intercollegiate Athletics, (530) 752-3680, merobles@ucdavis.edu
•Andy Fell, UC Davis News Service, (530) 752-4533, ahfell@ucdavis.edu
Dr. Joshua Brooks
Chiropractor Fairfax, VA 22031
Chiropractor Alexandria, VA 22304
August 10, 2010
Aggie player Paige Mintun goes for a layup and will be landing on those toes. (Wayne Tilcock/Davis Enterprise photo)
Anterior cruciate ligament injuries are a common and debilitating problem, especially for female athletes. A new study from UC Davis shows that changes in training can reduce shear forces on knee joints and could help cut the risk of developing ACL tears. The research was published online Aug. 3 in the Journal of Biomechanics.
"We focused on an easy intervention, and we were amazed that we could reduce shear load in 100 percent of the volunteers," said David Hawkins, professor of neurobiology, physiology and behavior at UC Davis. Hawkins conducted the study at the UC Davis Human Performance Laboratory with graduate student Casey Myers.
The anterior cruciate ligament lies in the middle of the knee and provides stability to the joint. Most ACL injuries do not involve a collision between players or a noticeably bad landing, said Sandy Simpson, UC Davis women's basketball coach.
"It almost always happens coming down from a rebound, catching a pass or on a jump-stop lay-up," Simpson said. "It doesn't have to be a big jump."
Hawkins and Myers worked with 14 female basketball players from UC Davis and local high schools. They fitted them with instruments and used digital cameras to measure their movements and muscle activity, and calculated the forces acting on their knee joints as they practiced a jump-stop movement, similar to a basketball drill.
First, they recorded the athletes making their normal movement. Then they instructed them in a modified technique: Jumping higher to land more steeply; landing on their toes; and bending their knees more deeply before taking off again.
After learning the new technique, all 14 volunteers were able to reduce the force passed up to the knee joint through the leg bone (the tibial shear force) by an average of 56 percent. At the same time, the athletes in the study actually jumped an inch higher than before, without losing speed.
Hawkins recommends warm-ups that exercise the knee and focusing on landing on the toes and balls of the feet. The study does not definitively prove that these techniques will reduce ACL injuries, Hawkins said: that would require a full clinical trial and follow-up. But the anecdotal evidence suggests that high tibial shear forces are associated with blown knees.
Hawkins and Myers shared their findings with Simpson and other UC Davis women’s basketball and soccer coaches, as well as with local youth soccer coaches.
Simpson said that the team had tried implementing some changes during last year's preseason, but had found it difficult to continue the focus once the full regular season began. In live play, athletes quickly slip back to learned habits and "muscle memory" takes over, he noted. More intensive off-court training and practice would be needed to change those habits, he said.
"We will be talking about this again this season," Simpson said. Implementing the techniques in youth leagues, while children are still learning how to move, might have the most impact, he said.
About UC Davis
For more than 100 years, UC Davis has engaged in teaching, research and public service that matter to California and transform the world. Located close to the state capital, UC Davis has 32,000 students, an annual research budget that exceeds $600 million, a comprehensive health system and 13 specialized research centers. The university offers interdisciplinary graduate study and more than 100 undergraduate majors in four colleges — Agricultural and Environmental Sciences, Biological Sciences, Engineering, and Letters and Science. It also houses six professional schools — Education, Law, Management, Medicine, Veterinary Medicine and the Betty Irene Moore School of Nursing.
Media contact(s):
•David Hawkins, Neurobiology, Physiology and Behavior, (530) 752-2748, dahawkins@ucdavis.edu
•Mike Robles, Intercollegiate Athletics, (530) 752-3680, merobles@ucdavis.edu
•Andy Fell, UC Davis News Service, (530) 752-4533, ahfell@ucdavis.edu
Dr. Joshua Brooks
Chiropractor Fairfax, VA 22031
Chiropractor Alexandria, VA 22304
Wednesday, August 18, 2010
Efficacy of spinal manipulation for chronic cervicogenic headaches
Headaches are among the common complaints in patients presenting for professional care. Patients with headaches often seek chiropractic care because they find spinal manipulation or adjustments applied to the cervical spine and upper back region are highly effective in reducing the intensity, frequency and duration of the headache pain. This is because the cervical spine is often the origin of the headache as the nerves in the upper neck pass through the thick, overly taught neck muscles in route to the scalp/head. When the muscles of the neck are in spasm, the nerves get irritated or squeezed by the overly tight muscles resulting in headache pain.
A research study published in October 2009 issue of The Spine Journal, Western States Chiropractic College, Center for Outcomes Studies, reported benefits are obtained with the utilization of spinal manipulation in the treatment of chronic cervicogenic headaches. The word “chronic” means at least 3 months of headache pain has been present. This new study compared 2 different doses of therapy using several outcome measures including the pain grade, the number of headaches in the last 4 weeks and the amount of medication utilized. Data was collected every 4 weeks for a 24 week period and patients were treated 1-2 times/week and separated into either an 8 or a 16 treatment session with half the group receiving either spinal manipulative therapy or a minimal light massage (LM) control group.
The results of the study revealed the spinal manipulation group obtained better results than the control group at all time intervals. There was a small benefit in the group that received the greater number of treatments with the mean number of cervicogenic headaches reduced by 50% in both pain intensity and headache frequency.
The importance of this study is significant as spinal manipulation therapy (SMT) offers a perfect remedy for patients who doesn't want to utilize medications in the treatment of headaches. Combine SMT with dietary management, lifestyle modifications, stress management, and vitamin/herbal anti-inflammatory (such as ginger, turmeric, boswellia) when needed, a natural approach to the management of chronic headaches can be accomplished.
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
A research study published in October 2009 issue of The Spine Journal, Western States Chiropractic College, Center for Outcomes Studies, reported benefits are obtained with the utilization of spinal manipulation in the treatment of chronic cervicogenic headaches. The word “chronic” means at least 3 months of headache pain has been present. This new study compared 2 different doses of therapy using several outcome measures including the pain grade, the number of headaches in the last 4 weeks and the amount of medication utilized. Data was collected every 4 weeks for a 24 week period and patients were treated 1-2 times/week and separated into either an 8 or a 16 treatment session with half the group receiving either spinal manipulative therapy or a minimal light massage (LM) control group.
The results of the study revealed the spinal manipulation group obtained better results than the control group at all time intervals. There was a small benefit in the group that received the greater number of treatments with the mean number of cervicogenic headaches reduced by 50% in both pain intensity and headache frequency.
The importance of this study is significant as spinal manipulation therapy (SMT) offers a perfect remedy for patients who doesn't want to utilize medications in the treatment of headaches. Combine SMT with dietary management, lifestyle modifications, stress management, and vitamin/herbal anti-inflammatory (such as ginger, turmeric, boswellia) when needed, a natural approach to the management of chronic headaches can be accomplished.
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
Saturday, August 7, 2010
Neck Injury in a Motor Vehicle Collision and Future Neck Pain
The objective of this population-based cohort study was to investigate the association between a lifetime history of neck injury from a motor vehicle collision and the development of troublesome neck pain. The current evidence suggests that individuals with a history of neck injury in a traffic collision are more likely to experience future neck pain. However, these results may suffer from residual confounding. Therefore, there is a need to test this association in a large population-based cohort with adequate control of known confounders.
A cohort of 919 randomly sampled Saskatchewan adults with no or mild neck pain in September 1995 were formed. At baseline, participants were asked if they ever injured their neck in a motor vehicle collision. Six and twelve months later, we asked about the presence of troublesome neck pain (grade II–IV) on the chronic pain grade questionnaire. Multivariable Cox regression was used to estimate the association between a lifetime history of neck injury in a motor vehicle collision and the onset of troublesome neck pain while controlling for known confounders. The follow-up rate was 73.5% (676/919) at 6 months and 63.1% (580/919) at 1 year.
A positive association between a history of neck injury in a motor vehicle collision and the onset of troublesome neck pain after controlling for bodily pain and body mass index was found. The analysis suggests that a history of neck injury in a motor vehicle collision is a risk factor for developing future troublesome neck pain. The consequences of a neck injury in a motor vehicle collision can have long lasting effects and predispose individuals to experience recurrent episodes of neck pain.
A study published in the British Journal of Orthopaedic Medicine (1999)22(1):22-25 reported that chiropractic is the only proven effective treatment in chronic cases of whiplash injury. The study was prompted by a previous article in the journal Injury which demonstrated that chiropractic treatment had benefited 26 out of 28 patients suffering from chronic whiplash syndrome.
Reference: Nolet P.S., Côté P., Cassidy J.D., Carroll L.J. The association between a lifetime history of a neck injury in a motor vehicle collision and future neck pain: a population-based cohort study. European spine journal 2010(MAR 7).
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
A cohort of 919 randomly sampled Saskatchewan adults with no or mild neck pain in September 1995 were formed. At baseline, participants were asked if they ever injured their neck in a motor vehicle collision. Six and twelve months later, we asked about the presence of troublesome neck pain (grade II–IV) on the chronic pain grade questionnaire. Multivariable Cox regression was used to estimate the association between a lifetime history of neck injury in a motor vehicle collision and the onset of troublesome neck pain while controlling for known confounders. The follow-up rate was 73.5% (676/919) at 6 months and 63.1% (580/919) at 1 year.
A positive association between a history of neck injury in a motor vehicle collision and the onset of troublesome neck pain after controlling for bodily pain and body mass index was found. The analysis suggests that a history of neck injury in a motor vehicle collision is a risk factor for developing future troublesome neck pain. The consequences of a neck injury in a motor vehicle collision can have long lasting effects and predispose individuals to experience recurrent episodes of neck pain.
A study published in the British Journal of Orthopaedic Medicine (1999)22(1):22-25 reported that chiropractic is the only proven effective treatment in chronic cases of whiplash injury. The study was prompted by a previous article in the journal Injury which demonstrated that chiropractic treatment had benefited 26 out of 28 patients suffering from chronic whiplash syndrome.
Reference: Nolet P.S., Côté P., Cassidy J.D., Carroll L.J. The association between a lifetime history of a neck injury in a motor vehicle collision and future neck pain: a population-based cohort study. European spine journal 2010(MAR 7).
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
Friday, July 30, 2010
What Triggers Headaches?
Whether you’re a headache sufferer or not, you probably know someone who is. Many simply reach for a pain reliever and try to put their headache behind them. Headaches may be common, but they’re not normal! In my chiropractic office in Greenbelt, MD our patients benefit from safe, natural chiropractic care.
Common Headache Triggers
Stress – Hectic lives, work schedules and insufficient sleep are common culprits
Sleep – Either too much or too little can trigger headaches in some people. Try to keep a regular sleep schedule.
Diet – Certain foods, such as chocolate, red wine, MSG, aged cheeses, caffeine and processed foods can bring one on.
Smells – Strong odors, such as nail polish, smoke, paint, perfume, and cleaning products can cause headaches in certain people.
Injury – Headaches are a primary symptom of whiplash and whiplash associated disorder (WAD).
Eyestrain – If you stare at a computer monitor all day or squint because you need glasses, you might experience frequent headaches.
Subluxation/Joint Fixation – If you have hunched shoulders, a restricted cervical curve, restricted movement in your neck or hear grinding sounds, it may be the underlying cause of your headaches.
Chiropractic care has shown impressive results in helping those who get frequent headaches.
Dr. Louis S. Crivelli II
Chiropractor
Greenbelt, MD
Common Headache Triggers
Stress – Hectic lives, work schedules and insufficient sleep are common culprits
Sleep – Either too much or too little can trigger headaches in some people. Try to keep a regular sleep schedule.
Diet – Certain foods, such as chocolate, red wine, MSG, aged cheeses, caffeine and processed foods can bring one on.
Smells – Strong odors, such as nail polish, smoke, paint, perfume, and cleaning products can cause headaches in certain people.
Injury – Headaches are a primary symptom of whiplash and whiplash associated disorder (WAD).
Eyestrain – If you stare at a computer monitor all day or squint because you need glasses, you might experience frequent headaches.
Subluxation/Joint Fixation – If you have hunched shoulders, a restricted cervical curve, restricted movement in your neck or hear grinding sounds, it may be the underlying cause of your headaches.
Chiropractic care has shown impressive results in helping those who get frequent headaches.
Dr. Louis S. Crivelli II
Chiropractor
Greenbelt, MD
Tuesday, July 27, 2010
Effectiveness of manual therapy for chronic tension-type headache
Chronic tension-type headache has a considerable impact on daily functioning and work participation, it is also a risk factor for overuse of analgesic medication. Only about 20% of the chronic tension-type headache patients seek medical care for their headache. This low consultation rate may be explained by insufficient information on the effectiveness of treatments or by previous negative health care experiences.
The pathogenesis of chronic tension-type headache remains unclear, however, in recent research a correlation between chronic tension-type headache and impairment of the cranio-cervical musculoskeletal function (forward head position, trigger points trapezius muscle, neck mobility) has been demonstrated. In combination with results obtained in previous studies the present data support the hypothesis that improvement of the cranio-cervical musculoskeletal function by a manual therapy intervention (postural correction, mobilization of cervical spine, and training of cervical muscles) may be an important factor to modify central or peripheral pain mechanism in chronic tension-type headache.
The purpose of this study in Cephalgia was to evaluate the effectiveness of manual therapy in participants with chronic tension-type headache, the authors of this study conducted a multicenter, pragmatic, randomised, clinical trial with partly blinded outcome assessment. Eighty-two participants with chronic tension-type headache were randomly assigned to manual therapy or to usual care by the general practitioner. Primary outcome measures were frequency of headache and use of medication. Secondary outcome measures were severity of headache, disability and cervical function.
After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the manual therapy group. Disability and cervical function showed significant differences in favour of the manual therapy group at 8 weeks but were not significantly different at 26 weeks. Manual therapy is more effective than usual general practitioner care in the short and longer term in reducing symptoms of chronic tension-type headache.
Reference: Castien RF, van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: A pragmatic, randomised, clinical trial. Cephalalgia. 2010 Jul 20.
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
The pathogenesis of chronic tension-type headache remains unclear, however, in recent research a correlation between chronic tension-type headache and impairment of the cranio-cervical musculoskeletal function (forward head position, trigger points trapezius muscle, neck mobility) has been demonstrated. In combination with results obtained in previous studies the present data support the hypothesis that improvement of the cranio-cervical musculoskeletal function by a manual therapy intervention (postural correction, mobilization of cervical spine, and training of cervical muscles) may be an important factor to modify central or peripheral pain mechanism in chronic tension-type headache.
The purpose of this study in Cephalgia was to evaluate the effectiveness of manual therapy in participants with chronic tension-type headache, the authors of this study conducted a multicenter, pragmatic, randomised, clinical trial with partly blinded outcome assessment. Eighty-two participants with chronic tension-type headache were randomly assigned to manual therapy or to usual care by the general practitioner. Primary outcome measures were frequency of headache and use of medication. Secondary outcome measures were severity of headache, disability and cervical function.
After 8 weeks (n = 80) and 26 weeks (n = 75), a significantly larger reduction of headache frequency was found for the manual therapy group. Disability and cervical function showed significant differences in favour of the manual therapy group at 8 weeks but were not significantly different at 26 weeks. Manual therapy is more effective than usual general practitioner care in the short and longer term in reducing symptoms of chronic tension-type headache.
Reference: Castien RF, van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: A pragmatic, randomised, clinical trial. Cephalalgia. 2010 Jul 20.
Dr. David P. Chen
Chiropractor in Laurel, MD 20708
Laurel Regional Chiropractic
Wednesday, July 21, 2010
Electric Muscle Stimulation and Rehab
Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Reviewfrom Journal of Orthopaedic & Sports Physical Therapy - JOSPT Site-Wide RSS
Kyung-Min Kim, Ted Croy, Jay Hertel, Susan Saliba
STUDY DESIGN: Systematic literature review.
OBJECTIVE: To perform a systematic review of randomized controlled trials assessing the effects of neuromuscular electrical stimulation (NMES) on quadriceps strength, functional performance, and self-reported function after anterior cruciate ligament reconstruction.
BACKGROUND: Conflicting evidence exists regarding the effectiveness of NMES following anterior cruciate ligament reconstruction.
METHODS: Searches were performed for randomized controlled trials using electronic databases from 1966 through October 2008. Methodological quality was assessed using the Physiotherapy Evidence Database Scale. Between-group effect sizes and 95% confidence intervals (CIs) were calculated.
RESULTS: Eight randomized controlled trials were included. The average Physiotherapy Evidence Database Scale score was 4 out of possible maximum 10. The effect sizes for quadriceps strength measures (isometric or isokinetic torque) from 7 studies ranged from –0.74 to 3.81 at approximately 6 weeks postoperatively; 6 of 11 comparisons were statistically significant, with strength benefits favoring NMES treatment. The effect sizes for functional performance measures from 1 study ranged from 0.07 to 0.64 at 6 weeks postoperatively; none of 3 comparisons were statistically significant, and the effect sizes for self-reported function measures from 1 study were 0.66 and 0.72 at 12 to 16 weeks postoperatively; both comparisons were statistically significant, with benefits favoring NMES treatment.
CONCLUSION: NMES combined with exercise may be more effective in improving quadriceps strength than exercise alone, whereas its effect on functional performance and patient-oriented outcomes is inconclusive. Inconsistencies were noted in the NMES parameters and application of NMES. LEVEL OF EVIDENCE: Therapy, level 1a–.
Dr. Joshua Brooks
Chiropractor Fairfax, VA 22031
Chiropractor Alexandria, VA 22304
Kyung-Min Kim, Ted Croy, Jay Hertel, Susan Saliba
STUDY DESIGN: Systematic literature review.
OBJECTIVE: To perform a systematic review of randomized controlled trials assessing the effects of neuromuscular electrical stimulation (NMES) on quadriceps strength, functional performance, and self-reported function after anterior cruciate ligament reconstruction.
BACKGROUND: Conflicting evidence exists regarding the effectiveness of NMES following anterior cruciate ligament reconstruction.
METHODS: Searches were performed for randomized controlled trials using electronic databases from 1966 through October 2008. Methodological quality was assessed using the Physiotherapy Evidence Database Scale. Between-group effect sizes and 95% confidence intervals (CIs) were calculated.
RESULTS: Eight randomized controlled trials were included. The average Physiotherapy Evidence Database Scale score was 4 out of possible maximum 10. The effect sizes for quadriceps strength measures (isometric or isokinetic torque) from 7 studies ranged from –0.74 to 3.81 at approximately 6 weeks postoperatively; 6 of 11 comparisons were statistically significant, with strength benefits favoring NMES treatment. The effect sizes for functional performance measures from 1 study ranged from 0.07 to 0.64 at 6 weeks postoperatively; none of 3 comparisons were statistically significant, and the effect sizes for self-reported function measures from 1 study were 0.66 and 0.72 at 12 to 16 weeks postoperatively; both comparisons were statistically significant, with benefits favoring NMES treatment.
CONCLUSION: NMES combined with exercise may be more effective in improving quadriceps strength than exercise alone, whereas its effect on functional performance and patient-oriented outcomes is inconclusive. Inconsistencies were noted in the NMES parameters and application of NMES. LEVEL OF EVIDENCE: Therapy, level 1a–.
Dr. Joshua Brooks
Chiropractor Fairfax, VA 22031
Chiropractor Alexandria, VA 22304
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