Webster Technique: A chiropractic technique for pregnant women

Supermodel and pregnant mom Gisele Bundchen spotted leaving her chiropractor's office June 23, 2009

Chiropractic care in pregnancy is an essential ingredient to your prenatal care choices. A large percent of all pregnant women experience back discomfort/ pain during pregnancy. This is due to the rapid growth of the baby and an interference to your body’s normal structural adaptations to that growth.

 

Dr. Larry Webster, Founder of the International Chiropractic Pediatric Association discovered The Webster Technique as a safe means to restore proper pelvic balance and function for pregnant mothers. This has been shown to reduce the effects of intrauterine constraint, allowing the baby to get into the best possible position for birth. In expectant mothers presenting breech, there has been a high reported success rate of the baby turning to the normal vertex position. This technique has been successfully used in women whose babies present transverse and posterior as well. It has also successfully used with twins. Any position of the baby other than ROA may indicate the presence of sacral subluxation and therefore intrauterine constraint. At no time should this technique be interpreted as an obstetric, “breech turning” technique. Untrained individuals should not attempt the Webster Technique.

The Webster Technique is defined as “a specific chiropractic analysis and adjustment that reduces interference to the nerve system and facilitates biomechanical balance in pelvic structures, muscles and ligaments.”  

The ICPA, founded by Dr. Webster, maintains the only database of chiropractors certified in the proper performance of the Webster Technique. In addition, the ICPA currently offers the only courses to certify chiropractors in the proper performance of it.   Dr. Catherine Caldwell-Chu, is a member of the ICPA and had received training and certification in the Webster Technique.  |To find me in the database please search “Catherine Chu”. 

Sources:   International Chiropractic Pediatric Association (http://www.icpa4kids.org)

What is whiplash really?

Is President Obama at risk for whiplash?

Most people know the term whiplash to mean a neck injury after a quick or strong turning of the head.  Although your wife or mother may have warned you against checking out the women passing by on the sidewalk, saying you are going to get whiplash, the disorder is normally the result of motor vehicle accident (MVA).

 

For the healthcare workers who treat whiplash and the insurance adjustors who monitor the claims of whiplash resulting from car accidents the term is much more specific.   In fact the real term is Whiplash Associated Disorder or “WAD”.  Whiplash merely refers to the mechanism of injury, acceleration-deceleration forces to the neck and the “associated disorder” part of the term refers to the symptoms resulting from those forces.     There are grades of WAD injuries depending on the symptoms the patient presents with.

The Québec Classification of WAD is a clinical classification system which grades symptoms as follows (1):

• Grade 0 WAD refers to no neck complaints and no physical signs (that is, no WAD injury, and thus outsidethe mandate of the Neck Pain Task Force),

• Grade I WAD refers to injuries involving complaints of neck pain, stiffness or tenderness, but no physical signs,

• Grade II WAD refers to neck complaints accompanied by decreased range of motion and point tenderness (musculoskeletal signs)

• Grade III WAD refers to neck complaints accompanied by neurologic signs such as decreased or absent deep tendon reflexes, weakness and/or sensory deficits

• Grade IV WAD refers to injuries in which neck complaints are accompanied by fracture or dislocation (and thus outside the mandate of the Neck Pain Task Force)

• Other symptoms such as deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain can be present in all grades.

The symptoms of WAD are thought to result from cervical sprain or strain, probably from soft tissue damage to ligaments and muscles in the neck.  In more serious cases, there can also be irritation to the nerves in the neck. Although the vertebrae and joints of the neck may also be involved, serious damage to the bones such as fracture or dislocation, require immediate medical attention and therefore a grade 4 WAD is a medical emergency and usually not referred to as whiplash by the medical community.

Helmet set flying after a big hit

Even though traffic collisions are the most common reason for whiplash neck complaints, as mentioned above any acceleration-deceleration force can cause a WAD injury. Contact sports like football, hockey, rugby and even soccer have the risk of causing a WAD neck injury.   If you experience any neck pain or stiffness after a traffic collision or any neck trauma, your chiropractor can assess your symptoms and provide a treatment plan to put you on the road to recovery.

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[i] Holm LW, Carroll LJ, Cassidy JD, et al. The burden and determinants of neck pain in whiplash-associated disorders

after traffic collisions. Results of the Bone and Joint Decade. 2000-2010 Task Force on Neck Pain and Its Associated

Disorders. Spine 2008;33(Suppl):S52-S59.

Snapping hip syndrome….you didn’t know your hip could snap did you?

You might be surprised to hear that your hip can “pop” or “snap”. Not everyone experiences this, but some people do complain of hearing or even feeling a pop or snap in their hip while running, dancing or playing sports. This is painful for some and nothing more than a nuisance or embarrassment for others. If this sounds likes a problem you are experiencing talk to your chiropractor about the possibility of snapping hip syndrome or coxa saltans (fancy latin words for hip and jumping).

There are three types of snapping hips – internal, intraarticular and external.

Reproducing the snapping

 These all refer to the area and structures in the hip that are causes the snapping sensation. The external presentation is more common and can be caused by the iliotibial band, tensor fascia lata or gluteus maximums tendon over the greater trochanter. Runners will report pain or snapping lateral to the greater trochanter, or on the outside of the hip between the buttock and thigh. Usually this occurs when a bent leg is straightened. In the case of internal or intraarticular snapping the patient will likely point to the anterior or front of the hip between the bony front of the hip bone (ASIS bone) and the groin area. This condition is usually caused by the iliopsoas tendon over the anterior hip capsule, lesser trochanter, femoral head or pectinus eminence. The internal type can be caused by loose bodies, labral tears, fracture fragments or synovial chrondometaplasia. There are muscle tests and motions your doctor will perform to determine if and what type of snapping hip you present with.

The good news is this condition, once it is properly diagnosed, can be treated simply and safely without surgery, corticosteroid injections or weeks away from your sport. Successful treatments include ART® tissue management systems, muscle stretching, and a strengthening regime or targeted muscles.

Anatomy of the hip

　

Sources:

An Overview of Hip Injuries in Running. Sports Med 2005; 35 (11): 991-1014

External coxa saltans (snapping hip) treated with Active Release Techniques(r): a case report.  JCCA 2007; 51(1): 23-29 

Understanding back surgery

Tuesday, 11.10.2009 / 7:31 PM / News

NHL.com

The blackhawks will be without Bolland for 3-4 months

The Chicago Blackhawks said Tuesday that center Dave Bolland, a 23 year old native of Mimico, Ontario, underwent successful surgery to repair a herniated disk in his back. The surgery was performed by Dr. Richard Fessler at Northwestern Memorial Hospital under the supervision of Blackhawks Head Team Physician Dr. Michael Terry.

“Dave underwent minimally invasive surgery today for a herniated disk,” Terry said. “The surgery went well and we anticipate a full recovery. He should be back in 12 to 16 weeks.”

Initially you might think, he is so young, why would he need back surgery.  Or perhaps you had a herniated disc before and it didn’t need surgery so why did Dave Bolland need it?

Stages of disc injury leading to herniation

Being a chiropractor I could go on at length about disc herniations and surgery but in order not to bore you I will keep it brief.   A herniated disc basically means that the gel like substances, called the nucleus polposus, has leaked out from the disc between two vertebrae in the lower back.  The most common location for this to happen is in the low back between the 5^th lumbar vertebrae and the sacrum.  The typical presentation will be an active young male in their 20’s to 30’s.  As we age the disc material “dries up” so there is less chance of it leaking out. There are various stages of disc herniations but the interesting thing is that studies have proven that there is no absolute connection between the severity of disc bulge or herniation and symptoms the person complains of.  The pain resulting from this injury can be from the disc itself which is damaged, as well from the nerve impingement.  Typically we explain this to our patients as the disc material coming out from between the bones is putting pressure and causing pressure on the adjacent nerve in the low back.  Irritation on this nerve results in local low back pain as well as radiated pain down the leg, loss of sensation and weakness in muscles of the calf and foot.   If ever the patient complains of loss of sensation on the skin around the genitals and anus or problems controlling bowel and bladder function associated with their low back pain that is a medical emergency.    Below is a 2 minute video from WorkSafe BC explaining how disc protusions/herniations can develop.

Surgeons remove the disc to relieve pressue off the nerve and reduce pain

Now that you hopefully understand a bit what a disc herniation is I will briefly explain the surgery.  From the cases I am familiar with the surgery, called a discectomy, is performed where an incision is made in the lower back to expose the area.  The leaking disc is removed as a way to relieve pressure of the nerve, which hopefully gets rid of the pain the patients is experiences.  After the disc is removed the vacant space between the two vertebrae is filled in with bone chips usually taken from the hip, the two bones are now fused together resulting in loss of movement at the joint in the back.   Success rate for back surgery varies from 60% to 90% [i], meaning that 10% to 40% of patients still have symptoms after surgery, and of course with any surgery there are the other associated risks.  Conservative treatment of chiropractic adjustments and physical therapy and time are recommended for most people before considering surgery.    Dave Bolland went for surgery because he is an elite athlete being paid to play and they want him back as soon as possible.

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[i] Spine:  August 2009 – Volume 34 – Issue 17 – pp 1839-1848

Dethroning the almighty antibiotic

I stopped into the walk in medical clinic in my area today for a MDs opinion of what  I thought might be a chronic ear infection that would not go away.  He checked my ear and since my eardrum looked red and “not happy” he gave me a prescription for an antibiotic.   I am not the type to go running to the MDs office looking for a prescription for every problem but in this case due to the chroncity I believe the prescripton may be warranted. 

The point of me telling you this is to share a surprising piece of  information that was posted on the bullentin board of the exam room.  (I had to read something while I waited on the paper lined table for 35 minutes for the doctor to come in). There was a poster titled  The Children’s Antibiotic Creed. I came home through the wonderful powers of goggle I found this document was based on the work of a McMaster University professor named Ross Pennie.  Dr. Pennie is an advocate against the over prescription of anitbiotics, especially to young children and infants.  He has authored several journal articles on the subject.  

Methicillin-resistant Staphylococcus aureus (MRSA) or "superbugs" resistant to normal antibiotics are created by the current abuse of prescription antibiotics

I would encourage health professional, parents and people working with young children to read about this “Antibiotic Saftey Zone” .   The first statement  reads  ” We aviod prescribing antibiotics unless they are clearly needed because sometimes antibiotics can do more harm than good.”  On the website you can download PDF posters and handouts to post in your home, office or day-care centre. 

Needless to say I am pleased that certain members of the medical community have admitted that antibiotics are not the answer to every complaint and recognize that in many cases if left alone the body can clear the illness on its own.

To the birthday boy!

My baby boy is growing up.   Technically he isn’t even a baby anymore. The term infant implies less than one year old and he had his first birthday last month.   My son William is now a todder, in every sense of the word.   He has progressed from sitting, through crawling, to climbing and he has been walking and running all over the house since he was 9 ½ months old.   No matter the agility or independence he showed, I was holding on to the fact that he is my little baby.  However, in light of his first birthday I have come to embrace the term toddler as I watch him learn and grow everyday.  

In reference to my son I thought it would be relevant to outline general developmental baby milestones to except around 12 months.  If you have specific concerns it is always best to discuss them with your baby’s health care provider. 

Motor Development

• Get from sitting to crawling to lying position
• Pulls self up to stand and may stand without assistance
• walk alone or while holding on to furniture
• cast – objects are “cast” or thrown from the hand
  

  Watch out for your head - babies soon learn to throw everything

• use a pincer grip – so he will be able to pick small objects up between index finger and thumb
• poke with the index finger
• release objects when taken from him – before this he is likely to hold ferociously
• put objects into containers – toys into toy box or cookies into a cup

Speech and Language Development

• use 2 to 3 words specifically “dada” and “mama”
• understand familiar names and words
• Is attentive to speech
• Understand & responds to simple verbal requests “give it to mommy”
• Responds to your “no”
• Babbles with inflection
• Uses exclamations like “Uh-oh!”
• Tries to imitate words

Personal / Social Development

• indicate his needs in new ways besides crying
• take off his shoes or socks
  

  You turn you back for a minute and their shoes and socks are off

• drink from a sippy cup
• finger-feed himself
• extends arm or leg to help when being dressed
• repeats sounds or gestures for attention
• Enjoys imitating people in play
• Shows preferences for certain people and toys
• Tests parental responses during feedings  (i.e. clamps lips shut)
• Tests parental responses to her behavior (i.e. cries and waits to see what you do)
• Starts to show temper

Cognitive

• Explores objects in a variety of ways (i.e. shaking, banging, throwing, dropping)
• Finds hidden objects easily  
• Looks at correct picture when image is named
• Imitates gestures
• Starts to use objects correctly (i.e. drinks from cup, brushes hair, dials phone)
• Laughs at funny things

Sources:

Personal experience

http://www.baby-medical-questions-and-answers.com/baby-development.html

http://www.childbirthconnection.org/article.asp?ck=10542

Muscular trigger points

You have probably been to the chiropractor or maybe the massage therapist and when they are feeling around your muscles, they hit a super painful location that seems to radiate pain to different parts of your body.    They tell your to relax while their thumb is jammed deep in your muscle and you want to scream.  If this is familiar to you then you have discovered what a trigger point is.  Fun isn’t it? 

Myofasical trigger points are areas of hyperirritability located in a taut band of muscle and resemble a rope like nodular area within a muscle that is painful on palpation or refers pain, tenderness and an autonomic response to a remote area.  Examples of autonomic responses are increased or decreased skin temperature, sweating or dryness.  Some potential causes are trauma, overuse, mechanical overload, postural faults, or psychological stress.

Trigger points can be described as active, latent, secondary or satellite.  An active trigger point is one that causes pain at rest or activity with a muscle.  A latent trigger point does not cause pain unless it is palpated, but may restrict movement or cause a weakness of the muscle.  Secondary trigger points are the result of muscle overload in a muscle that is substituting for another, stronger muscle or in the anatagnosit to the muscle containing the primary trigger point.  An example would be a trigger point in the piriformis developing as a result of its substituting for the gluteus maximus in the external rotation of the hip. Finally, a satellite trigger point is located withing the sone of referred pain from the primary trigger point.  An example of this is a trigger point in the piriformis producing a satellite in the hamstrings.

Less commonly know types are ligamentous and periosteal trigger points.  Ligamentous trigger points are found in lax, stretched ligaments.  These trigger points are extremely sensitive to further stretching and may fire on prolonged maintenance of stressful positions or postures.  They are typically associated with weak, tight muscles.  Perisoteal trigger points are found on the surface of bone most commonly at the sites of ligament or tendon attachment.

Some trigger points and referral patterns are  illustrated in the diagrams below.  The ‘x’ in the picture represents the location of the trigger point itself, the tight band where the chiropractor would put their finger/thumb and the red shading indicates the referral area of that trigger point.  This is why a chiropractor may treat your elbow or shoulder in order to get rid of pain in the hand or wrist, or back muscles to relieve buttock pain, etc.  The three pictures below are trigger points for; upper fibers of trapezius muscle, erector spinae longissimus muscle and subscapularis muscle.

 

 

Sources: 

Bachrach, Richard M.  Trigger points for trainers and clients, 2007.  http://www.bonesdoctor.com/triggerpoints.html

Haten, William P., Olson Sharon L., Butts, Nicole L., and Nowicki, Aimee L.  Effectivenss of a home program of ischemic compression followed by sustained stretch for treatment of myofasical trigger points.  Phyiscal therapy, 2000; 80(10): 997-1003.

Is your morning coffee helping or harming you?

The Canadian Favorite

Double-double, latte, regular, black, decaf, tall, low fat, espresso.  Whether you like it simple or fancy, coffee is reported to be among the most widely consumed beverages in the world.   It is a complex chemical mixture reported to contain more than a thousand different compounds.  Recently, coffee has been associated with lowering your risk of several chronic diseases.  Could a healthier life be as close as a cup of coffee away? Or maybe you are worried that too much coffee will increase your risk for breast cancer.  Let’s see what the research has to say.

Potential Health Benefits

There are many benefits to drinking coffee

Coffee consumption has been shown to reduce the risk of developing type 2 Diabetes Mellitus by as much as 50% in people who drink at least 7 cups a day.  Elderly men drinking one cup of coffee a day had a about half the risk of developing Parkinson’s disease over the next 10 years than those who did not drink coffee.  Unfortunately this inverse relationship was not found in women, possibly due to the estrogen issues of menopause.  A 10 year study found the suicide risk decreased 13% for every cup of coffee consumed daily.  Case control studies found colorectal cancer risk was 24% lower in those that drank four or more cups a day than non drinkers.  However, when combining larger studies this association could not be found with higher levels of research. The blood of coffee drinkers has lower GGT and ALT compounds which are both markers for liver damage.  Linked to that are studies that report a 40% lower risk of death from liver cirrhosis in women who drink 2 cups a day and those who drank 5 cups a day had a 76% hepatocellular carcinoma than those who never drank.

Potential Health Risks

Are you a caffeine junkie?

There is talk that coffee consumption is a risk for cardiovascular diseases, such as coronary heart disease, cardiac arrhythmias, and stroke risk.  The link is present in some case control studies but the majority of prospective cohort studies have not found significant associations between the coffee consumption and cardiovascular diseases.  Coffee does have an effect of cholesterol levels which is a health problem related to cardiovascular disease.   Filtered coffee, the way most north Americans prepare it, raised total cholesterol by 3mg/dl and did not affect LDL cholesterol.   Coffee also raises plasma homocysteine levels (a bad thing) but this may be prevent by ensure proper amounts folic acid.  In general recent studies have not observed significant associations between coffee/caffeine and risk of pancreatic, bladder, ovarian, breast, gastric and prostate cancer.  Coffee does have a negative effect on calcium absorption and bone mineral density.  A person can lose approximately 4-6mg of calcium per cup of coffee.  Four out of six studies found no change in the bone mineral density of those drinking coffee, however one study found an accelerated bone loss when consuming at least 300mg caffeine a day and another study found bone loss only in women consuming less than 744mg/calcium a day.  In addition to lower the absportion of calcium, coffee also inhibits the absorption of iron by 24-73% and zinc by 21-32%.

What about pregnant women and those who are trying to become pregnant?

Some studies have found high intakes of caffeine ranging from 400-800mg/day were associated with longer time become pregnant.  Studies have concluded that the talk about a link between coffee and spontaneous abortion has not been demonstrated.  However, coffee intake should be limited to 300mg/day during pregnancy because there are some studies that show link between low birth weight and high caffeine intake.  For breastfeeding mothers caffeine does pass into breast milk within 15 minutes and it peaks about 1 hour after consumption.  Although high maternal caffeine intake is reported to cause irritability and poor sleeping patterns in infants, no adverse effects have been reported with moderate intake of 2-3 cups per day.

So should you have you cup of coffee?

Yes.  Coffee is a wonderfully delicious and social beverage. There are many demonstrated health effects but coffee shouldn’t be thought of as a way to prevent disease.  Also, if you want to receive any of the health benefits of coffee you can’t mix it with cigarette or other bad habits, like sleep deprivation or alcohol use.  The best recommendations for a long healthy life include the old favourites of exercises, well balanced diet, mental and social engagements.

Source: Higdon, J and Frei B.  Coffee and Health: A review of recent human research.  Critical reviews in food sciences and nutrition.  46: 101-123. 2006.

Be your own health advocate

Be your own health advocate

This topic is coming from a personal experience with my family’s health.   I just found out my 1 year old son has a hydrocele, which is basically fluid collection around his scrotum.   His doctor first thought the bulge I described seeing around my son’s groin was a hernia.  However when the ultrasound came back normal he dismissed the problem saying it would go away.  It wasn’t until I bought the issue up at his next appointment five months later, that the doctor thought he should investigate further.  The paediatrician has now diagnosed him with a hydrocele and is prescribing surgery to repair it.  The morale to this is that trust yourself.  You know your own body and when something isn’t right, find the answer. Even though I am a health professional myself, I fell into the same trap as many people do, I trusted the MD’s opinion too much.  I knew something was abnormal and I should have perused the issue harder from the start.  Now I am doing my research and will be more prepared when we have the consultation with the surgeon.

What is a hydrocele? [i]

A hydrocele is a fluid-filled sac surrounding a testicle that results in swelling of the scrotum, the loose bag of skin underneath the penis. About one in 10 male infants has a hydrocele at birth, but most hydroceles disappear without treatment within the first year of life. Additionally, men — usually older than 40 — can develop a hydrocele due to inflammation or injury within the scrotum.

What causes this condition?[ii]

During development, the scrotal cavity in boys is connected to the abdominal cavity via a structure called the processus vaginalis. The processus vaginalis usually closes at birth, or soon after.

When the processus vaginalis does not close, or closes after fluid from the abdomen has become trapped in the scrotal cavity, it is called a hydrocele. The canal (inguinal canal) between the abdominal cavity (peritoneum) and the scrotum remains open. Fluid from the peritoneum enters the canal and the scrotum, and causes swelling of the scrotum. In some cases, bowel can also pass through the processus vaginalis into the scrotum. This is called an inguinal hernia.  It is difficult to distinguish the two conditions upon physical exam so further testing my be necessary.

What is the treatment?

If a hydrocele persists past the first six to 12 months of life, it should be surgically repaired. Surgery usually completely corrects the defect, and the long-term prognosis is quite excellent. Hydrocele repair is done on an outpatient basis and recovery is usually brief. Most children can return to normal activity within about four to seven days.

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[i] Mayo Foundation for medical education and research (MFMER).  Nov 28, 2007  http://www.mayoclinic.com/print/hydrocele/DS00617/DSECTION=all&METHOD=print

[ii] Hydrocele repair series.   Medline Plus.  9/7/2008.  http://www.nlm.nih.gov/medlineplus/ency/presentations/100163_1.htm

Suffering with headaches…so is the rest of the world

Headaches are a common aliment worldwide.  A comprehensive literature search identifying population-based studies on headache and migraine published from 1988 to present was conducted.   Studies were collected documenting headache data from 43 different countries across six continents.  The resulting data estimates that globally, 46% of adults have an active headache disorder[1].  That includes people suffering from migraines (11%), tension-type (42%) and chronic daily headache (3%).  The life time prevalence or odds that you will suffer from a headache some point in your life, is higher: 66% for headache, 14% for migraine, 46% for tension type headache.

How do you know what type of headache you are suffering from?

Properly diagnosing a headache disorder can be difficult.  There are several different categories of headaches and subcategories within those, and for that reason doctors often ask for as much detail about the headache as a patient can give.  To aid in diagnosis and constancy across health fields, the International Headache Society[2] has developed criteria for the classification of headache types.  For a complete listing and understanding of the headache types please visit their website.  The more common headache types are briefly listed below.

1. Migraine (with and without aura)
   

   blurred or spotty vision before a headache is call an aura

Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia

1. Tension type (TTH)

Frequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.

1. Cluster

The runny nose, watery eye and throbing pain over the eyebrown of a cluster headache is more common in males

Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema. Most patients are restless or agitated during an attack

1. Headache attributed to head and/or neck trauma

Headache is a symptom that may occur after injury to the head, neck or brain. Frequently, headache that results from head trauma is accompanied by other symptoms such as dizziness, difficulty in concentration, nervousness, personality changes and insomnia. This constellation of symptoms is known as the post-traumatic syndrome; amongst them, headache is usually the most prominent.

Irriated joints and muscles in the neck can cause headaches

What treatment is available for your headache?

There is no need to suffer with your headache disorder.  Today’s health professionals are well trained and able to deal with your complaint.  A chiropractor can offer safe, drug free treatments that are proven to help reduce many types of headaches. Chiropractic adjustments and mobilizations to the joints in the neck, as well as soft tissue therapy to the affected muscles have showed to be give relief from headaches.   If you are unsure about having you neck adjusted, speak to your chiropractor, there are other ways to treat headaches.

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[1] Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher AI, Steiner TJ &

Zwart J-A. The global burden of headache: a documentation of headache

prevalence and disability worldwide. Cephalalgia 2007; 27:193–210.

[2] http://ihs-classification.org/en/02_klassifikation/