Understanding Diabetic Neuropathy

Regular Post

22 Jan

Diabetic Neuropathy, Pain Relief, Peripheral Neuropathy, Pain Management, Nerve Pain Treatment, Carolina Pain Scrambler, Greenville South Carolina

Understanding Diabetic Neuropathy

Over time, your diabetes can cause nerve damage that can lead to neuropathy. The increased and uncontrollable levels of glucose (sugar) cause the neuropathy. Commonly, affecting the nerves in your arms, hands, legs or feet for some even problems are seen in the digestive system, heart, blood vessels, and urinary tract. Pain, tingling, numbness, disabling, and even death are some complications of diabetic neuropathy. Often, diabetic neuropathy develops gradually and signs and symptoms may not appear until major damage has occurred to your nerves. The neuropathy can often be prevented if glucose levels are under control along with maintaining a healthy diet and exercise. The four common types of diabetic neuropathy include:

Peripheral Neuropathy

The common form of diabetic neuropathy is first seen in toes, feet, and legs and then in hands and arms. The signs and symptoms such as pain, tingling, burning sensation, cramps, numbness, or reduced feeling to pain and temperature are often heightened at night. Peripheral neuropathy also presents with muscle weakness, loss of reflexes, and increased sensitivity to touch, loss of balance, coordination. It may also show ulcers, infections, deformities, bone and joint pain in the foot.

Autonomic Neuropathy

In this neuropathy, you will notice neural changes in your autonomic system that controls your digestion, bowel, heart, bladder, lungs, eyes, and sex organs. The signs and symptoms you should look for are hypoglycemia unawareness, difficulty swallowing, erectile dysfunction in men, urinary tract infections, urinary incontinence or retention. Other changes to notice include a change in perspiration, vaginal dryness, sexual difficulties in women, issues regulating body temperature, unable to regulate blood pressure and heart rate, increased heart rate while resting, and the ability for your eyes to adjust from light to dark. A few other issues are constipation, uncontrollable diarrhea, and the slow emptying of the stomach.

Radiculoplexus Neuropathy

This neuropathy is also known as diabetic amyotrophy, proximal, and femoral neuropathy that damages the nerves to the hips, thighs, gluts, or legs. This neuropathy is often seen in type 2 diabetics and older adults with diabetes. The signs and symptoms are often seen unilaterally, on one side of the body, and often worsen before you see any relief. Radiculoplexus neuropathy presents with abdominal swelling, weight loss, weak, atrophied thigh muscles and difficulty standing from a sitting position. You will also notice sudden, severe pain in hip, thigh, or gluts.

Mononeuropathy

Mononeuropathy is also referred to focal neuropathy that affects a particular nerve often in the head, torso, or leg. Usually occurs in older adults with diabetes, comes on suddenly without causing much long-term issues, and lasts for a few weeks to months. This neuropathy causes inability to focus on your eyes, double vision, aching behind one eye, or paralysis unilaterally known as Bell’s palsy. You may also notice pain in your lower back, pelvis, shin, foot, chest, abdomen, or front of the thigh.

Article Provided By: PainScale

If you would like to discuss what Carolina Pain Scrambler do to help relieve your chronic pain symptoms or receive more information on our treatment process, please do not hesitate to call us at 864-520-5011 or you can email us at info@carolinapainscrambler.com

Regular Post

20 Jan

Chronic Pain, Pain Relief, Pain Management, Pain Treatment, Peripheral Neuropathy, Nerve Pain Treatment, Carolina Pain Scrambler, Greenville South Carolina, Insomnia

Insomnia and Chronic Pain

What is insomnia?

Insomnia is a sleep disorder which manifests as difficulty falling asleep, staying asleep, or going back to sleep after prematurely waking. Individuals with insomnia often don’t get the recommended seven to eight hours of uninterrupted sleep, leading to a lack of energy during their waking hours. Insomnia can be acute (lasting days or weeks) or chronic (lasting a month or more).

The symptoms of insomnia include, but are not limited to, difficulty sleeping, tiredness during waking hours, irritability, depression, anxiety and impaired concentration. Insomnia is more likely to affect individuals who are over the age of 60, who are under significant stress, who do not have a consistent schedule, or who have physical or mental health conditions, such as chronic pain. Women are also at a higher risk of developing insomnia than men.

Insomnia and chronic pain

The link between insomnia and chronic pain is complex — chronic pain can cause insomnia, and insomnia can increase chronic pain. One study found moderate to severe insomnia in 53% of study participants with chronic pain in comparison to just 4% of similar pain-free participants. Additionally, individuals with insomnia due to chronic pain report more severe, long-lasting pain in comparison to individuals with chronic pain without insomnia. Chronic pain can interrupt or even prevent sleep, and lack of restorative sleep can reduce pain thresholds and even produce pain symptoms.

Diagnosis

Insomnia is usually diagnosed during a physical exam and a discussion about sleep habits with a health care provider. A sleep study may also be recommended to check for other sleep-related disorders, such as sleep apnea or restless legs syndrome.

Treatments

Cognitive behavioral therapy (CBT)
CBT is one of the primary treatments for insomnia. CBT involves learning how to change thought patterns and behaviors. This type of therapy is extremely effective in the treatment of insomnia.
Medication
Over-the-counter sleep medications are available for purchase; however, they are not designed for long-term use. A doctor or pharmacist should be consulted before taking these medications. Sleep medications for short- or long-term use can be prescribed by a health care provider. Caution should be exercised when taking medication for sleep because side effects, such as daytime drowsiness and dizziness, are common. Sleep medications can also be habit-forming.
Herbal and dietary supplements
Herbal and dietary supplements, such as melatonin and valerian, may also help with sleeplessness. However, the long-term safety of melatonin is unknown, and long-term use of valerian may be linked to liver damage. Consulting a health care provider before trying any supplement(s) is highly recommended.
Alternative therapies
Alternative therapies, such as acupuncture, yoga and meditation, may help reduce stress and improve sleep quantity and quality.
Sleep hygiene
Practicing good sleep hygiene may help ease insomnia. Sleep hygiene involves reducing exposure to light before bedtime, going to bed and getting up at the same time each day, and keeping the bedroom dark and quiet.

Article Provided By: PainScale

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17 Jan

Chronic Pain, Pain Relief, Peripheral Neuropathy, Pain Treatment, Nerve Pain Treatment, Pain Therapy, Carolina Pain Scrambler, Greenville South Carolina

How Chronic Pain Impacts Older Adults

Chronic pain can affect many aspects of life, such as sleep, mood and physical activity. This is especially true for older adults (>65).

Chronic pain and sleep

Individuals with chronic pain often deal with sleep issues. Frequent waking can occur after experiencing a day of heightened pain. For some individuals, the natural act of turning over in bed can cause pain. Sleep issues are especially prevalent in the older adult chronic pain population. As people age, the body’s production of melatonin naturally decreases resulting in reduced sleep. Older adults are twice as likely to report difficulty falling asleep and increased time spent in bed. Due to lack of sleep, the body is not able to properly restore energy reserves, which leads to fatigue and inactivity the next day. A vicious cycle of bad quality sleep, lower pain thresholds and the reduced ability to cope with chronic pain may result.

Chronic pain and depression

The relationship between chronic pain and depression is complex. Chronic pain can cause depression, and depression can lead to heightened chronic pain levels. Older adults are more reticent to share any experienced mental health symptoms with a health care provider, which makes diagnosis and treatment difficult. Depression can disrupt cognitive function and create a lack of concern about healthy eating, which can result in malnutrition and low energy levels.

Chronic pain and physical activity

The idea of exercise can seem counterintuitive as a pain-reduction method. However, gentle exercise can actually decrease pain levels. Because the experience of chronic pain is highly individualized, the choice of exercise should be, also. Older adults may be hesitant to exercise due to the fear of falling. Walking or warm-water exercise is often recommended for older adults.

Article Provided By: PainScale

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15 Jan

Chronic Pain, Pain Relief, Pain Therapy, Nerve Pain Treatment, Peripheral Neuropathy, Carolina Pain Scrambler, Greenville South Carolina

Chronic Pain Is Often Invisible

Because chronic pain often doesn’t show any visible symptoms, friends, colleagues or even family often have a difficult time understanding the impact that chronic pain has on an individual’s life. Also, because the cause of chronic pain is sometimes difficult to diagnose, physicians may not take an individual’s pain levels seriously. Since chronic pain is often invisible, these are some of the reasons it can be difficult to diagnose.

Various reasons for disbelief

Medical students only receive a few hours of training in pain management. This does not provide a sufficient understanding of the experiences of individuals with chronic pain. Unfortunately, this can lead to health care providers dismissing an individual’s pain if an identifiable cause is not apparent. Certain factors may play into the disbelief of an individual’s chronic pain, such as their young age or healthy appearance. Some health care providers may dismiss individuals with chronic pain as drug-seekers or individuals with a mental illness.

The effect of skepticism

Not only do individuals with chronic pain cope with physical symptoms on a daily basis, they often have to deal with skepticism from others, especially if their chronic pain is “invisible.” This can lead to doubting oneself, low self-esteem, isolation and depression. It is important for individuals with chronic pain to find support, whether among trusted family and friends, in a support group or with a medical professional.

Doctors who specialize in chronic pain

An individual’s chronic pain should be acknowledged and validated during a visit to a health care provider. Having an open dialogue about chronic pain with a health care provider builds trust. Asking for a referral to a health care provider who is specially trained in pain management, such as a physiatrist (physical medicine and rehabilitation physician) or an anesthesiologist, is a good first step in receiving a proper diagnosis and treatment plan.

Article Provided By: PainScale

Regular Post

13 Jan

Chronic Pain, Pain Relief, Pain Management, Pain Therapy, Pain Treatment, Peripheral Neuropathy, Carolina Pain Scrambler, Greenville South Carolina

Lifestyle for People with Chronic Pain

Individuals with chronic pain can take an active role in leading healthier, happier lives by incorporating healthy lifestyle habits into their everyday routines.

Making self-care a priority

Oftentimes, family and work take precedence over self-care. This can lead individuals with chronic pain to put symptoms of pain and fatigue on the back-burner. Unfortunately, by doing this, pain levels and fatigue can increase and family relationships and work are ultimately neglected. Individuals should make self-care a priority to ensure that other aspects of their lives remain healthy, too.

Managing stress

Juggling work, family and personal obligations naturally creates stress which can easily become amplified during an intense bout of chronic pain. Unfortunately, chronic pain also tends to amplify stress. This can become a harsh, never-ending cycle. Enjoyable activities, such as taking a walk, reading a book, listening to music or watching a funny movie (laughter is good medicine) distract the mind from pain and ease stress.

Exercising and meditation

Gentle exercise, meditation and massage are valuable tools in an effective pain management plan. By staying active and focusing on breathing, the body and mind relax, which can have a positive impact on chronic pain.

Eating healthy

Individuals should eat “the rainbow” by incorporating a wide variety of fruits and vegetables into their diet. Fruits and veggies contain loads of antioxidants that promote the battle of free radicals (unstable atoms that can cause chronic pain and other health conditions).

Article Provided By: PainScale

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10 Jan

Chronic Pain, Pain Relief, Peripheral Neuropathy, Nerve Pain Treatment, Pain Therapy, CRPS, Carolina Pain Scrambler Center, Greenville South Carolina, Hope

Finding Hope with Chronic Pain

Living with chronic pain is often frustrating and disheartening. Because chronic pain is unpredictable in severity and frequency, individuals who live with it are often forced to alter their lifestyles in order to cope. Activities that were once enjoyed may no longer be possible, family and friends may not understand and daily routines may need to be adjusted. Accepting a chronic pain diagnosis is difficult, especially when first diagnosed. However, finding hope and a new purpose in life is possible. Some tips that may help individuals accept and manage a life with chronic pain include the following:

Keep a gratitude journal

Writing about the blessings in life actually trains the brain to perceive things more positively. It may sound simple, but even jotting down 3 blessings a day slowly changes an individual’s outlook. It may be something basic like “the beautiful sunset” or “a friend stopped by to chat.”

Talk about It

Chronic pain can be more than frustrating, it can also make an individual feel isolated. Talking about emotions with trusted friends and family can help. Simply talking about day-to-day experiences and emotions offers a release, which helps decrease stress levels.

Meditate

An effective way to reduce pain and anxiety is meditation. Even if individuals only meditate for 10 minutes per day, the positive impact on their lives can be drastic.

Exercise

Although it may seem counter-intuitive, exercise is an excellent way to decrease pain levels. Engaging in a daily low-impact exercise routine is beneficial for the body and mind. Before beginning any exercise program, individuals should discuss it with a health care provider to ensure it is a good choice for their condition.

Maintain a sense of humor

The saying, “Laughter is the best medicine” holds plenty of truth. Studies show that laughing releases “feel good” chemicals in the brain which help to reduce pain.

Join a support group

Sharing with others that also have chronic pain helps individuals realize they are not alone. Not only does the individual receive support, they can also offer support to others which, oftentimes, provides hope and purpose in their chronic pain journey.

Start a sleep routine

Lack of proper sleep often increases pain levels. Developing a sleep routine is important. Keeping the bedroom cool and clutter free promotes healthy sleep. Powering down all electronics, taking a warm bath or shower and drinking caffeine-free tea an hour before bed relaxes the body and brain.

Visit a specialist

Chronic pain is often too complex for a family doctor to treat. It is imperative to find a specialist who has worked with chronic pain patients. They can provide a proper diagnosis and treatment plan.

Article Provided By: PainScale

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8 Jan

Chronic-Fatigue and Chronic Pain

Carolina Pain Scrambler

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Individuals with chronic pain conditions often experience chronic-fatigue. Characteristics of fatigue include reduced energy, profound weariness and excessive sleepiness. The symptoms of fatigue often interrupt everyday life; unfortunately, sleep and rest usually do not alleviate the symptoms. An estimated 10 to 40 percent of individuals with chronic pain also have chronic fatigue. Excessive sleepiness and lack of motivation during the day are often a sign of fatigue. If symptoms of fatigue last for six months or longer, individuals should visit a health care practitioner to identify the cause. Chronic fatigue syndrome (CFS) may be to blame.

The relationship between fatigue and chronic pain

Fatigue affects individuals both physically and mentally. As chronic pain symptoms increase, fatigue symptoms tend to intensify and vice versa. This becomes a vicious cycle leading to feelings of loneliness and hopelessness. Lack of quality sleep causes chronic pain to increase, which lowers energy, resulting in fatigue. Loss of muscle mass, due to inactivity caused by chronic pain, leads to fatigue symptoms. Fatigue can be debilitating, making everyday tasks impossible. Treating symptoms of fatigue concurrently with symptoms of chronic pain can help increase physical and mental activity, regain focus, reduce depression symptoms and decrease pain levels.

Causes of fatigue

Fatigue is a symptom of and contributor to various health conditions. These include inflammatory diseases, irritable bowel syndrome, fibromyalgia, chronic headaches, complex regional pain syndrome (CRPS), multiple sclerosis, Parkinson’s disease, mononucleosis, thyroid disease and cancer.
Other possible causes of fatigue include, but are not limited to, the following:

Medications, including opioid pain medications
Hypothyroidism
Low testosterone
Sleep apnea
Lack of restorative sleep

Article Provided By: PainScale

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6 Jan

Diabetic Neuropathy, Pain Relief, Peripheral Neuropathy, Chronic Pain, Pain Management, Pain Treatment, Carolina Pain Scrambler, Greenville South Carolina

Types of Diabetic Neuropathy

Diabetic neuropathy is nerve damage caused by diabetes. It is a condition that usually damages nerves in your legs and feet as a result of extended periods of time with elevated levels of blood glucose. Depending on which nerves are affected, symptoms of diabetic neuropathy may vary from pain and numbness in the extremities to problems with the digestive system, urinary tract, blood vessels and heart. Though diabetic neuropathy is a serious complication, symptoms may be prevented through a healthy lifestyle and careful control of blood sugar levels.

There are four primary types of diabetic neuropathy. An individual may experience symptoms from one type or more. Most develop gradually and may cause considerable damage before it is noticed. The four types include Peripheral Neuropathy, Autonomic Neuropathy, Radiculoplexus Neuropathy, and Mononeuropathy.

Peripheral Neuropathy is the most common type. The feet and legs are affected first followed by the hands and arms. Symptoms include numbness, tingling, burning sensation, increased sensitivity to touch, muscle weakness, loss of reflexes, loss of balance, and serious foot problems.
Autonomic Neuropathy affects the autonomic nervous system which controls multiple organs in the body including the stomach, lungs, intestines, eyes, and heart. Some symptoms are related to dysfunction of an organ system, including bladder problems, constipation, problems regulating body temperature, and increased heart rate while at rest.
Radiculoplexus Neuropathy affects nerves in the thighs, hips, buttocks or legs, causing sudden pain. This condition is more common in people with type 2 diabetes and the elderly. Symptoms usually occur on one side of the body. Other symptoms include atrophied thigh muscles, difficulty rising from a sitting position, and weight loss.
Mononeuropathy occurs when there is damage to a specific nerve possibly located in the face, torso, or leg. Though mononeuropathy can be severely painful, it doesn’t generally cause long term problems. Symptoms usually dissipate after a few weeks or months. Symptoms include difficulty focusing the eyes, paralysis on one side of the face, pain in the foot, lower back, pelvis, and front of the thigh, chest or abdomen.

Article Provided By: PainScale

Regular Post

30 Dec

Chronic Pain, Pain Relief, Peripheral Neuropathy, Nerve Pain Treatment, Pain Management, Pain Treatment, Carolina Pain Scrambler, Greenville South Carolina, Prevention

Prevention Tips for Chronic Pain

The approach to pain management largely depends on what’s causing the pain. When it’s a byproduct of an ongoing health condition, the focus is finding a good pain management strategy to keep discomfort at a minimum. But when it’s rooted in an isolated event or injury, you can focus not only on treatment, but also the prevention of chronic pain. In situations like this, it’s worth asking – can you keep acute pain from becoming chronic? The answer isn’t simple – pain is complex and unique to each individual – but there are some things that you can do to prevent pain from taking hold in the long-term. And, similar to other chronic diseases like diabetes and heart attacks, one of the keys to prevention is understanding the risk. Certain events have been identified as being high risk for developing chronic pain.

Surgeries. Though most all surgeries are painful, some are particularly associated with developing chronic pain: mastectomies, thoracotomies (opening up the chest), joint replacements, amputations, and spine surgeries like laminectomies and fusions. With each of these different types of surgeries, it is common to experience persistent nerve pain related to the operation. There are ongoing studies looking for ways to block excessive nerve irritation during these surgeries, including starting anti-neuropathic pain medications, like pregabalin, gabapentin, and venlafaxine prior to the surgery. If you have a procedure scheduled, talk to your surgeon ahead of time to see if this would be appropriate for your situation.
Acute trauma. Acute trauma, like motor vehicle accidents or fall injuries, carries an elevated risk of chronic pain. There are usually multiple reasons for this, related to both physical and psychological factors. High-impact injuries from events like falling off of a ladder or getting rear-ended on the freeway cause significant jarring to joints, ligaments, tendons, and nerves of the body, causing a chain reaction that leaves the musculoskeletal system over-tensed and the nervous system over-activated in such an intense way that it may not let up. The emotional response to the injury only serves to further amplify this response. Behavioral health experts often work with patients to treat anxiety, and even PTSD, that is often associated with going through traumatic injuries. Reducing symptoms of distress early after an injury can play a key role in promoting a quicker recovery and diminishing the chances of progressing into chronic pain.
Low back pain. Unlike other acute injuries, like a sprained ankle, where rest is a necessary part of the recovery process, low back injuries don’t heal as well with prolonged bed rest. Recovery is quicker when appropriate movements and a return to typical daily activities are started early on after a back injury. For added guidance on safe exercises and activities, consider working with a movement specialist such as a physical therapist, chiropractor, or Pilates instructor until you feel comfortable doing things on your own.

Past studies suggest that belief patterns also play a role in the development of chronic pain. For example, catastrophizing, when you think the absolute worst about a given situation, can lead to feelings of anxiety, depression, fear, and hopelessness. Catastrophizing is a known risk factor for developing chronic pain, while feeling more optimistic seems to be associated with improvements in health and well-being. One theory on how chronic pain can develop is known as fear-avoidance, where pain or even the anticipation of pain creates so much fear about further injury, that a person starts to shut down and avoids certain movements. These behavioral changes brought on by high levels of fear are felt to increase the likelihood of developing more widespread and lasting pain. One way that can help patients change unhealthy perceptions is by approaching things in a very slow and deliberate fashion. Each little accomplishment along the way builds confidence, and the more confidence that is built, the easier it is to wash away negative feelings like fear and anxiety that stand in the way of recovery.With so many different factors contributing to chronic pain, the approach to prevention should be multidimensional – better education, the right medications, exercise and physical therapy, counseling, and even good nutrition. If you are experiencing acute pain, talk to your doctor about how you might leverage these tools to keep your pain from transitioning into a chronic problem.

Article Provided By: WebMD

Regular Post

23 Dec

Pain Management, Pain Relief, Chronic Pain, Pain Treatment, Peripheral Neuropathy, Carolina Pain Scrambler Center, Greenville South Carolina

Pain Management During the Holidays

The holiday season can be an intense time for many chronic pain patients, with plenty of highs and lows. The pressure of participating in family get-togethers, shopping for gifts, and hosting gatherings can easily turn up stress levels. And more stress often leads to worse chronic pain.

In addition to the extra activities and running around, the holidays can also be a highly emotional time. This can be a time of deeper depression, greater loneliness, and even feelings of loss or guilt. For some, mood changes at this time of year are a result of seasonal affective disorder, a form of depression associated with seasonal changes (often referred to as the “winter blues”). These mood changes can make pain management more difficult.

Seasonal weather changes can also affect the experience of chronic pain. Patients often say that the colder weather and changes in barometric pressure increase their pain levels.

Food can create problems, too. The holidays are often a time for baking and gatherings that are centered around food, and along with that come tempting treats and snacks. Many of these goodies may be high in sugar, and sugary foods are typically considered pro-inflammatory, meaning they increase tissue inflammation in places like painful joints. Processed savory foods, like cured meats and crackers, are often high in salt, which can lead to swelling and water retention around painful hotspots. Conditions like arthritis and fibromyalgia can certainly get aggravated by these pro-inflammatory foods, and certain cheeses, chocolate, and red wine, all popular during the holidays, serve as common triggers that migraine sufferers need to watch out for.

If you find yourself struggling more with chronic pain during this time of year, having a special plan in place for the holidays may be helpful. Here are some pain management tips to keep in mind when developing an effective game-plan:

Keep it simple. This can be a hectic time of year, with lots to get done, but adding extra tasks to your busy day may do more harm than good. Avoid trying to do too much by setting aside some down days to regroup and recharge. On your down days, make a point of doing something that you know will help reduce pain and stress, whether that be going for a nice walk, scheduling a visit with the chiropractor, or taking in a yoga class.
Laugh as much as possible. Some of your social interactions during this season may be stressful – it can be frustrating talking about your pain with friends or family members who aren’t sympathetic. So make a point of scheduling time to visit or call the special people in your life who know how to make you smile and giggle. And have a funny show or movie available for those times when some lightness is most needed.
Make an anti-inflammatory tool kit. An easy first step is to keep a bottle of plain water with you. Staying well-hydrated is really important, and drinking plenty of water is a good way to avoid overdoing it on sugary or alcoholic beverages. Having a bag of nuts handy is another effective preventive strategy to avoid over-eating pro-inflammatory treats, while filling up on healthy anti-inflammatory fats. Once you have the basics, then consider adding things to your tool kit that you happen to enjoy, like bags of green tea, ginger shots, or a mix of relaxing songs that put you in the right mood.

Hopefully these pain management tips will help you get the absolute best out of your holiday season!

Article Provided By: WebMD

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Neuropathic Pain Therapy Center

Understanding Diabetic Neuropathy

Peripheral Neuropathy

Autonomic Neuropathy

Radiculoplexus Neuropathy

Mononeuropathy

Insomnia and Chronic Pain

What is insomnia?

Insomnia and chronic pain

Diagnosis

Treatments

How Chronic Pain Impacts Older Adults

Chronic pain and sleep

Chronic pain and depression

Chronic pain and physical activity

Chronic Pain Is Often Invisible

Various reasons for disbelief

The effect of skepticism

Doctors who specialize in chronic pain

Lifestyle for People with Chronic Pain

Making self-care a priority

Managing stress

Exercising and meditation

Eating healthy

Finding Hope with Chronic Pain

Keep a gratitude journal

Talk about It

Meditate

Exercise

Maintain a sense of humor

Join a support group

Start a sleep routine

Visit a specialist

Chronic-Fatigue and Chronic Pain

The relationship between fatigue and chronic pain

Causes of fatigue

Types of Diabetic Neuropathy

Prevention Tips for Chronic Pain

Pain Management During the Holidays

Get Immediate Relief from Chronic Pain at Carolina Pain Scrambler Center!