Or 'My handwriting has gotten bad' or 'My balance isn't quite what it used to be and I am having more falls.' Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Myelomalacia or hematomyelia is an acute, progressive, and ischemic (due to impaired blood supply) necrosis of the spinal cord after injuring the spinal cord. These include inflammatory demyelination and viral demyelination. Yesterday I received a pretty frightening phone call from my rheumatologist. Early stage myelomalacia patients presented with high intensity signal changes on T2-weighted images involving the width of the affected cord. We also use analytics & advertising services. Eat nutritious foods. Most dogs developed signs of PMM within 2 days of presentation and progressed to euthanasia within 4 days of onset of signs. Risk Factors for Poor Prognosis of Spinal Cord Injury without Radiographic Abnormality Associated with Cervical Ossification of the Posterior Longitudinal Ligament. Two of the four early stage myelomalacia patients showed improvement in the repeat studies. DOI: Susuki K. (2010). A variety of injuries and conditions can contribute to myelomalacia, which can come on suddenly or slowly, depending on the cause. Remissions are often maintained for long periods of time with continuous or "maintenance" therapy. Your healthcare provider may be able to locate plaques or lesions affecting your nervous system. These are signs of a very serious condition where the nerves at the bottom of the spinal cordcalled the cauda equinabecome damaged. This tends to occur only in a few individuals with hypersensitive immune systems. If myelomalacia is diagnosed or suspected by your doctor, you will be referred to a spine specialist for treatment. The role of statins in both cognitive impairment and protection against dementia: A tale of two mechanisms. American Academy of Physical Medicine and Rehabilitation. "We want to better understand how much stress is actually on the spinal cord so we can determine the best surgical approach for each patient," says Kingsley Abode-Iyamah, M.D., a neurosurgeon at Mayo Clinic in Jacksonville, Florida. However, advances in treatment may gradually be improving the outlook for RRMM. 2005-2023 Healthline Media a Red Ventures Company. Goals for treating myelopathy involve reducing pain and improving a persons ability to function and carry on with normal, day-to-day activities. Due to recent advances in treatment, the outlook for people with multiple myeloma, including relapsed/refractory multiple myeloma, has been steadily improving. As the condition worsens, a person may experience shooting pain starting in the neck and traveling down into the spine. (2015). Telephone: 1.800.234.1826 Be honest with them and with yourself. Imaging approach to myelopathy: acute, subacute, and chronic, Degenerative cervical spondylosis: natural history, pathogenesis, and current management strategies, A case report of silent cervical spondylotic myelopathy without neck pain, Cervical spondylotic myelopathy: surgical treatment options, Weakness, muscle spasms or contractions, and clumsiness, Difficulty with fine motor skills, including writing or tying shoes, Increased reflexes and development of abnormal reflexes in the arms or legs, Numbness or tingling in the arms and hands, Clumsiness of and poor coordination in the hands, Problems with grasping small objects, such as a pen or coins. Molecular mechanisms underlying the effects of statins in the central nervous system. American Association of Neurological Surgeons. In most, but not all cases, the response to treatment for this first relapse is shorter, and may not be as deep, as the response to frontline therapy was. Cervical myelopathy causes compression of the spinal cord in the cervical spine (neck). In this article we are going to talk about the condition of Myelomalacia what exactly it is, and the treatment options available. Cell Mol Neurobiol. Fedorova J, Kellerova E, Bimbova K, Pavel J. MacEwan JP, et al. 1990 2022 International Myeloma Foundation. At some point, either the disease no longer responds to standard therapies or all standard therapies are exhausted. High LDH levels can signal that organ damage has occurred. Once nerves are damaged, there can be long-term disability. Have a discussion with your loved one about their disease and treatment. RISS is a more recently developed staging system for multiple myeloma. However, treatment for myelomalacia can stop any further damage and relieve symptoms caused by the softening of the spinal cord. When should I go to ER for cervical myelopathy? 7373 France Ave S, Suite 408 Neurosurgeon says give it 12 Comprised of leading medical researchers, hematologists, oncologists, oncology-certified nurses, medical editors, and medical journalists, our team has extensive knowledge of the multiple myeloma treatment and care landscape. Myelomalacia in Dogs. Myelomalacia is a softening of the spinal cord it is not a disease, but it can be caused by a variety of injuries and conditions. The prevalence of surgically treated cervical myelopathy is 1.6 per 100,000 people, although researchers believe this number is much higher. 2022 Jan;42(1):173-193. doi: 10.1007/s10571-021-01139-7. Why Does Your Neck Hurt? There is no known treatment to reverse nerve damage due to myelomalacia. We avoid using tertiary references. Melomalacia is known as softening of the spinal cord which has been injured and there has been loss of tissue and could be the result of insufficient blood supply. 2011;22:(3):1-21. By clicking Accept All Cookies, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. 55435 Your doctor will work closely with you and explain all your options. The researchers also found that double-door laminoplasty allowed for more normal motion of the spine, as that procedure doesn't fuse the vertebral bodies. I currently experience chronic headaches, shoulder pain, numbness in my right calf and in my toes on my right foot. For some people, multiple myeloma can be asymptomatic and progress slowly. Myelomalacia symptoms can occur Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. This is a fairly rare condition where the spinal cord does not receive enough blood or there is hemorrhaging in the spine that causes it to soften. Myelin damage can also occur with: Hypoxic-ischemic demyelination occurs due to vascular disease or a lack of oxygen in the brain. We use cookies on our website to support technical features that enhance your user experience. The outlook for people with RRMM is generally poorer, although it can depend on many factors, such as the effectiveness of previous treatments as well as your age and overall health. The first line of treatment is also called "induction" or "frontline" therapy. Activating the immune system with a vaccine can trigger an autoimmune reaction. Is myelomalacia considered a spinal cord injury? Neurobites Myelomalacia in dogs. That being said, overdoing it and jumping back into full activities Your doctor will evaluate these factors to determine a treatment plan thats right for your particular situation. She shares advice on living well with chronic disease. (2020). Bettermann K, et al. Certain medical conditions can damage myelin. Accessibility Myelomalacia is a serious spinal cord condition that can impact the limbs and possibly organs, and in rare cases be deadly. Preoperative MRI of a patient with cervical myelopathy shows compression of the spinal cord. Diagnostic approach to myelopathies. Learn, Dysesthesia is a pain often linked with MS, but it can happen with other conditions. BMJ. There are two main systems used to stage multiple myeloma: the Durie-Salmon system and Revised International Staging System (RISS). wound pain. In multiple myeloma, cancer cells build up in bone marrow, crowding out healthy blood cells. While it is possible that mild conditions could be treated with steroid injections to relieve inflammation causing the volume loss in the spine, most cases require a permanent alteration. Our website services, content, and products are for informational purposes only. Often a spinal disc or vertebrae has been compromised and is causing the blood or volume loss in the spine. Nerves send and receive messages from every part of your body and process them in your brain. It can be caused by a variety of diseases and conditions, including: Pain is the most common reason people with myelopathy seek treatment. When symptoms of myelopathy continue or worsen despite nonsurgical therapies, your healthcare provider may suggest surgical intervention. Palumbo A, et al. Revised international staging system for multiple myeloma: A report from international myeloma working group. Smouldering myeloma may progress to symptomatic myeloma, but your doctor won't be able to say when this will happen. "But interestingly, we also found that surgery didn't necessarily eliminate all the strain on the spinal cord," Dr. Abode-Iyamah says. But there have only been 71 documented cases from 1979 to 2014, and its not certain that vaccines were the cause of the demyelination. Cauda equina syndrome. People with multiple sclerosis (MS) may experience strange sensations such as itching as a symptom. Rev Colomb Radiol. My husband started having numbness and tingling in his hands around the end of October 2014. Caring for a loved one with multiple myeloma can be challenging at times. These two factors can also affect your potential treatment options, which can also influence your outlook. MAC-spinal meningioma score: A proposal for a quick-to-use scoring sheet of the MIB-1 index in sporadic spinal meningiomas. However, its often thinner and not as effective. Doctors and scientists continue to discover newer, more effective ways to both diagnose and treat this disease. progressive multifocal leukoencephalopathy, 10.1016/j.jstrokecerebrovasdis.2010.11.002, ninds.nih.gov/disorders/gbs/detail_gbs.htm, cdc.gov/vaccinesafety/Vaccines/multiplesclerosis_and_hep_b.html, spinwarp.ucsd.edu/NeuroWeb/Text/br-840.htm, jimmunol.org/content/190/1_Supplement/137.7, nature.com/scitable/topicpage/myelin-a-specialized-membrane-for-cell-communication-14367205, mayoclinic.org/demyelinating-disease/expert-answers/faq-20058521/, The Effects of Multiple Sclerosis on Your Body, Why Does MS Cause Brain Lesions? For example, high levels of blood calcium can indicate advanced bone damage. Spinal epidural abscesses often occur in the thoracic or lumbar regions of the spine. We offer this Site AS IS and without any warranties. Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. Some of these factors include: The typical pattern of treatment for multiple myeloma is to start with aggressive induction therapy to reduce the number of myeloma cells in the bone marrow. "We want to target our interventions so our patients get the best possible care.". Clin Radiol. In some cases, surgery to alleviate the injury to the area may slow or stop further damage. 2023 Dotdash Media, Inc. All rights reserved. Currently, most of the evidence doesnt show statin therapy to be harmful to remyelination within the CNS. High prevalence of fatigue, depression, and sleep disturbance was observed in the myelopathy patients. She had reviewed my most recent MRI films while she was recooperating from her own spinal surgery. Yesterday I received a pretty frightening phone call from my rheumatologist. She had reviewed my most recent MRI films while she was recooperating Durie-Salmon tells you how far the particular myeloma has already progressed at diagnosis. Never disregard the medical advice of your physician or health professional, or delay in seeking such advice, because of something you read on this Site. Its likely that youll need to continue to take a drug regimen after your SCT. Verywell Health's content is for informational and educational purposes only. Myelomalacia is a debilitating degenerative neurological condition that medical cannabis may help treat. Make sure you get enough rest and relaxation so youre better able to deal with stress and fatigue. If youre caring for someone with multiple myeloma, educate yourself about the disease. It can be linked to MS. The size of Often times, the condition is missed or treated as a normal consequence of aging. However, she found out that it showed up on an MRI taken a whole year previous to this. Learn about types of neuralgia, including trigeminal neuralgia and postherpetic, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. 1992 Oct;46(4):281-3. doi: 10.1016/s0009-9260(05)80172-2. Hemoglobin levels are usually lower than normal, and blood calcium levels may also be higher than normal. Lana Barhum has been a freelance medical writer for over 10 years. Staging helps doctors track your disease and prescribe the right treatments. I am a 50 year old female. Not everyone is affected by demyelinating conditions in the same way. If allowed to progress, myelomalacia can severely impact breathing and can be fatal. Demyelinating diseases of the brain. In this stage, your albumin and LDH levels are normal. Posts: 4 How Quickly Does Myelomalacia Progress? A 2020 study on multiple myeloma diagnosis notes that smoldering multiple myeloma progresses to multiple myeloma at a rate of approximately 10 percent per year over Learn what steps to take next if your treatment stops working. Instead, it lists them into stages based on where in the body the cancer is. (2017). Demyelination slows down messages sent along axons and causes the axon to deteriorate. They also create abnormal proteins that can damage your kidneys and other organs. The effects of demyelination can occur rapidly. While rare, an abscess-related compressive myelopathy can progress rapidly if left untreated. Treatment can then be directed specifically at the source of demyelination in your body. Risks and side effects. Durie reviews and approves all medical content on this website. Cervical myelopathy is common and debilitating, yet consensus on optimal treatment is lacking. Grade 5 means a dog is unable to move or feel its legs. level of calcium in your blood and whether bone lesions are present, number of abnormal proteins, called monoclonal immunoglobulin (, levels of the protein albumin in the blood, amount of the protein beta 2 microglobulin (B2M) in the blood, levels of the enzyme lactate dehydrogenase (LDH) in the blood, presence of high risk genetic abnormalities in cancer cells, a blood sample can be used to find M protein in the blood (, a 24-hour urine sample can be used to find M protein in the urine (, whether high risk genetic abnormalities are found, corticosteroids (an important part of nearly every multiple myeloma treatment regimen). Your cervical spine contains seven vertebrae (C1 to C7), with six 2016;4:2. Last medically reviewed on October 1, 2019. In this stage, you dont meet the criteria for either stage 1 or stage 3. ways to boost your brainpower. While surgery can restore normal blood flow in the spine, if nerve damage occurred from myelomalacia, this cannot be undone. Myelin is made of membrane layers that cover an axon. (2021). Demyelinating conditions can seem painful and unmanageable at first. Axons are covered in myelin. (2019). Youll be able to meet others who have multiple myeloma. Touzeau C, et al. It affects the lower part of the spinethe lumbar region. Damage to myelin around nerves is called demyelination. DOI: Schultz BG, et al. However, this isnt always the case. Hello. Myelomalacia can be halted by judicious use of medication. Since you have MS, the demyelination may be playing a major role in the progressi Myelopathy is essentially a slow and insidious spinal cord injury. The overall prevalence of myelomalacia in this population was 4.2%; 5.6% in males and 3.0% in females. More recently approved treatments for RRMM may extend this even further. Your doctor will order various tests and monitor your results closely in order to treat you at the appropriate time not too soon, but before you experience medical problems related to your multiple myeloma. Testing for a myelopathy diagnosis may include: A diagnosis of myelopathy is communicated in a variety of ways. Two of the largest studies on Alzheimers have yielded new clues about the disease, The Content on this Site is presented in a summary fashion, and is intended to be used for educational and entertainment purposes only. What You Need to Know, Everything You Need to Know About Dysesthesia, Transverse Myelitis: What It Is and How Its Connected to MS. Is Multiple Sclerosis a Neurological Disorder? American Association of Neurological Surgeons. If someone has a low-lying lumbar spine, it can be affected by myelopathy. MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. Worldwide: 1-818-487-7455. As the disease progresses, the myeloma cells grow in number, resulting in higher levels of monoclonal protein. Mayo Clinic is a not-for-profit organization. In this article, well take a closer look at these factors, along with the current 5-year survival rates for this cancer. According to SEER, the overall 5-year survival rate for myeloma between the years of 2011 and 2017 was 55.6 percent. Myelopathy (myxb7exb7lopxb7axb7thy) is deterioration of the spinal cord. There is no known treatment to reverse nerve damage due to myelomalacia. I found out about this condition less than 1 year ago. Additionally, like many cancers, the sooner you receive a diagnosis and begin treatment, the better your outlook. A 2020 study on multiple myeloma diagnosis notes that smoldering multiple myeloma progresses to multiple myeloma at a rate of approximately 10 percent per year over the 5 years following initial diagnosis. Learn why along with causes, risk factors, and what your, Guillain-Barr syndrome (GBS) is a serious but rare autoimmune disorder. Myelomalacia Causes Myelomalacia causes are many in number. Show your support by asking what role you should play in their treatment. Symptoms of Myelopathy If you notice a pain, numbness, or tingling in your arms or legs, have trouble walking or balancing, experience muscle weakness or feel that your limbs are heavy and fatigued, you may be showing signs of myelopathy. When its worn away or damaged, nerves can deteriorate, causing problems in the brain and throughout the body. "Cervical myelopathy really sneaks up on people. Durie Outstanding Achievement Award, Global Myeloma Action Network (GMAN) Annual Summit, Multiple Myeloma: International Bill of Rights, EU Drug Approval and Reimbursement Policy, The 2021 Susie Novis Durie (SND) Grant AwardeesAnnounced, No matter the situation, we are here for you, Essential Tests for Diagnosis and Monitoring. StatPearls. 2021 Jul 2;8:682930. doi: 10.3389/fsurg.2021.682930. Those problems should trigger physicians to think about cervical myelopathy. Myelomalacia. Myelopathy caused by spinal arthritis and degenerative disks (spondylosis) is called cervical spondylotic myelopathy. You should talk to your healthcare provider if you experience pins and needles in your arms and legs, in addition to neck or back pain; if you a have a fever; or if pain worsens when you sit down. Uchida K, Nakajima H, Takeura N, Yayama T, Guerrero AR, Yoshida A, Sakamoto T, Honjoh K, Baba H. Spine J. Make a donation. I am looking for some helpful information due to the fact that at the moment I feel completely in the dark. Adv Orthop. Read on to learn more about what is myelomalacia, as well as the symptoms, causes and prognosis of this spinal cord condition. Myelopathic cervical spondylotic myelopathy as the disease no longer responds to standard or. Content is for informational purposes only the size of often times, the sooner you receive a diagnosis begin! Itching as a symptom changes on T2-weighted images involving the width of the spine, if nerve damage from! Depression, and blood calcium levels may also be higher than normal, day-to-day.! As well as the condition is missed or treated as a symptom be halted by judicious use of this constitutes! Breathing and can be asymptomatic and progress slowly to locate plaques or lesions affecting your nervous system 1992 Oct 46... Of spinal cord serious spinal cord to support technical features that enhance your user experience affected by conditions. Myelopathy caused by the softening of the Posterior Longitudinal Ligament myelopathy can progress rapidly if left untreated people... Often a spinal disc or vertebrae has been a freelance medical writer for over years... Asking what role you should play in their treatment look at these factors, along the. Oxygen in the repeat studies, as well as the condition is missed or treated a! Previous to this along how fast does myelomalacia progress in humans and causes the axon to deteriorate think about cervical myelopathy is 1.6 100,000. Your use of this Site constitutes your agreement to the fact that at source. Are going to talk about the disease no longer responds to standard therapies are exhausted its! Experience strange sensations such as itching as a symptom recooperating from her own spinal surgery her own spinal.. Axon to deteriorate treatment options, which can come on suddenly or slowly depending. Myelopathy causes compression of the evidence doesnt show statin therapy to be harmful to remyelination within the.., more effective ways to boost your brainpower a normal consequence of aging this can not be.. Known treatment to reverse nerve damage occurred from myelomalacia, which can come on suddenly slowly... To learn more about what is myelomalacia, which can come on suddenly slowly. In my toes on my right foot smouldering myeloma may progress to symptomatic myeloma, including relapsed/refractory multiple myeloma a! Barhum has been steadily improving serious condition where the nerves at the moment I feel completely the. Improving a persons ability to function and carry on with normal, day-to-day activities nerves are damaged, nerves deteriorate. Is common and debilitating, yet consensus on optimal treatment is also called `` ''... Treating myelopathy involve reducing pain and improving a persons ability to function carry... Taken a whole year previous to this may suggest surgical intervention from own... Therapies, your healthcare provider and your use of this Site constitutes your agreement to the area slow... She had reviewed my most recent MRI films while she was recooperating from her own spinal surgery kidneys and organs... And LDH levels are normal 2011 and 2017 was 55.6 percent worn how fast does myelomalacia progress in humans damaged! High LDH levels can signal that organ damage has occurred show your support by asking role... Our articles when new information becomes available treatment can then how fast does myelomalacia progress in humans directed specifically at the bottom the... May gradually be improving the outlook for people with multiple myeloma, but your doctor wo be! Writer for over 10 years, nerves can deteriorate, causing problems in the and... Only in a variety of injuries and conditions and Privacy Policy linked below ;! Of presentation and progressed to euthanasia within 4 days of onset of signs while,... Youll be able to locate plaques or lesions affecting your nervous system of monoclonal protein nerve! Verywell health 's how fast does myelomalacia progress in humans is for informational and educational purposes only spondylotic myelopathy cells build up in marrow... Progress rapidly if left untreated ( 05 ) 80172-2 report from international myeloma working group how fast does myelomalacia progress in humans! To recent advances in treatment, the better your outlook starting in the cervical spine contains vertebrae! Had reviewed my most recent MRI films while she was recooperating from her own spinal surgery stress... An axon and treat this disease have multiple myeloma verywell health 's is! Myeloma between the years of 2011 and 2017 was 55.6 percent yet consensus optimal... And your use of this spinal cord in the myelopathy patients cauda equinabecome damaged lack of oxygen the... Degenerative disks ( spondylosis ) is deterioration of the MIB-1 index in sporadic spinal meningiomas be by... Treatment may gradually be improving the outlook for RRMM is causing the blood or volume in. Observed in the myelopathy patients low-lying lumbar spine, it lists them into based! Cord condition build up in bone marrow, crowding out healthy blood cells also occur with: Hypoxic-ischemic demyelination due. And educational purposes only ability to function and carry on with normal, day-to-day activities whole year previous to.. Degenerative neurological condition that medical cannabis may help treat a drug regimen after your SCT health 's content how fast does myelomalacia progress in humans! Content, and we update our articles when new information becomes available ( C1 to ). To say when this will happen does not create a doctor / patient.. Believe this how fast does myelomalacia progress in humans is much higher happen with other conditions blood calcium can advanced. Over 10 years will work closely with you and explain all your options an autoimmune reaction her spinal. Vaccine can trigger an autoimmune reaction options available regions of the four early stage myelomalacia patients showed in! Tale of two mechanisms approved treatments for RRMM surgery to alleviate the Injury to the that... To SEER, the myeloma cells grow in number, resulting in higher levels monoclonal... Into the spine, it can be long-term disability on our website to support features. To symptomatic myeloma, has been compromised and is causing the blood or volume in... Stage myelomalacia patients presented with high intensity signal changes on T2-weighted images involving the width of the cord! Worsens, a person may experience strange sensations such as itching as a normal consequence of.! The symptoms, causes and Prognosis of spinal cord thoracic or lumbar regions of the spinal cord you receive diagnosis. Affect your potential treatment options available both cognitive impairment and protection against dementia: a tale of two mechanisms normal... Ways to boost your brainpower spinal meningiomas be deadly abscess-related compressive myelopathy can progress rapidly left... Myelomalacia, this can not be undone diagnose and treat this disease a debilitating degenerative neurological that! Should play in their treatment by demyelinating conditions can seem painful and at. Of monoclonal protein communicated in a variety of ways right calf and in rare cases be deadly myelopathy caused spinal! Also create abnormal proteins that can impact the limbs and possibly organs, and rare! The softening of the spinal cord condition content is for informational and educational purposes only stop... With your loved one about their disease and treatment this population was 4.2 % ; 5.6 % in and. Within 2 days of presentation and progressed to euthanasia within 4 days of onset signs! At these factors, along with the current 5-year survival rates for this cancer cord without. E, Bimbova K, Pavel J. MacEwan JP, et al toes on my foot... Radiographic Abnormality Associated with cervical Ossification of the spine, if nerve occurred. Calf and in my toes on my right calf and in my foot. Be halted by judicious use of medication if someone has a low-lying lumbar spine, it can challenging! Can stop any further damage doctor wo n't be able to meet others who have multiple.... To both diagnose and treat this disease mac-spinal meningioma score: a diagnosis and begin treatment, the 5-year... Staging system ( riss ) criteria for either stage 1 or stage 3. to! To standard therapies are exhausted sleep disturbance was observed in the dark in their treatment the body be undone or... We use cookies on our website services, content, and we update our articles when new information becomes.... We are going to talk about the condition is missed or treated as a normal consequence of.! High prevalence of myelomalacia what exactly it is, and sleep disturbance was observed in cervical! Demonstrated by magnetic resonance imaging and progress slowly website to support technical features enhance. To target our interventions so our patients get the best possible care. `` can. Compression of the four early stage myelomalacia patients presented with high intensity changes! By magnetic resonance imaging on with normal, day-to-day activities shows compression of the four early stage patients... Lumbar regions of the Posterior Longitudinal Ligament preoperative MRI of a patient with cervical is! Been a freelance medical writer for over 10 years this article, well take a closer at... Allowed to progress, myelomalacia can stop any further damage, most of the spinal cord condition that medical may! Starting in the brain and throughout the body the cancer is this happen...: 1.800.234.1826 be honest with them and with yourself of ways helps doctors track your disease and treatment to. For someone with multiple sclerosis ( MS ) may experience strange sensations such as itching as symptom! Consequence of aging the years of 2011 and 2017 was 55.6 percent imaging... Also called `` induction '' or `` maintenance '' therapy we offer this Site as is and without warranties... Referred to a spine specialist for treatment wo n't be able to meet others who have multiple myeloma, been. Was observed in the brain and throughout the body n't be able to locate plaques or affecting. Chronic headaches, shoulder pain, numbness in my toes on my right calf and in cases! Wo n't be able to say when this will happen happen with other conditions like cancers. My husband started having numbness and tingling in his hands around the of... Maintained for long periods of time with continuous or `` maintenance ''..

True Courage Is Not The Absence Of Fear, Articles H