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The Spine Long version By-Othon Molina, Ph.d.c, LMT First of all I want to make it clear that this information is not to diagnose nor prescribe, and it should not take the place of the advice of your doctor. This is intended to educate, back patients, not to replace conventional medicine. Consult with your doctor before starting any kind of physical program. Even though the spine is very strong, it seems to be a source of trouble. I think most of us have had some kind of back or neck problem during our life. If you haven t you are lucky, it can be a real pain and not just in the back. We hear sciatica mentioned often or a slipped disc, and then again we hear, I threw my back out . All of which are rather medically incorrect, and misleading. I can t tell you how many times I heard a patient say "I just bent down to pick up a newspaper and wham, I threw my back out." I was brushing my teeth, I coughed and "My back went out" I could buy a new house, if I had a buck for all the times I heard that. I think about 80 to 90 percent of people in the country have back or neck problems. The statistics say less, one out of three, I m not sure that s right. Most back and neck problems relate to injuries to some part of the spine complex, either the soft tissue or the discs, themselves. There is a lot of controversy about the neck and back problems. It s a very mysterious, part of the body. Mainly because there are many misconceptions about the back, it s pain and it s treatment. It takes a doctor that has experience with the back, as many general practitioners, may not always agree or have a clear diagnosis as to what is going on. First there are many similar symptoms that can come from different problems. The spine and it s structure This is one of the most fascinating parts of the body. There are over forty-eight major nerves that come out of the spine. The nerves are the network for the communication between the brain, the nervous system and the rest of the body. If you look at the spine you find that the twenty-six vertebrae are very odd shapes. They have all these protrusions (bumps) for attachments of ligaments and muscles. They are designed with precise mechanics so that the neck vertebras move easier than the lumbar ones. There is also three natural curves in the spine; This is for shock absorption action, for strength and leverage. A straight spine would have no give and not be as strong as a curve. There are seven smaller vertebrae in the neck, the top two called atlas and axis move freely in a twisting motion and are the only ones without a disc in between. Then we have the twelve thoracic vertebrae in the mid back, and five in the lumbar area of the low back. The base of the spine holds some vertebrae that where fused early in life that is called the sacrum. To me the sacrum is the foundation to the whole spine as well as the hinge that holds the pelvis together. It is the center of the hips, and there are a tremendous amount of ligaments that attach all of these bones together. There are also some of the larger gluteal muscles attaching at this site. The spine not only has some of the largest muscle groups woven through the vertebras there are also hundreds of small muscles and ligaments that attach to it and provide the support and movement. A very common area for low back pain as far as injuries to the discs, and ligaments is at the L4-L5 Lumbar, and the SI Joint (Sacro Iliac Joint). Between each of the vertebras of the spine lies a cushion type cartilage called a disc. The disc is made up of two kinds of cartilage: a hard outer layer and a soft, spongy, jelly type center. The discs give your back the shock absorbent qualities and the resilience to endure between 1000 to 1,500 pounds of shock and stress on the spine. Part of the vertebra at the rear protects the spinal cord, in vertebra there is a hole in the middle. These holes line up together and form a long tunnel. This is where the spinal cord and it s nerves are located. The nerves, exit out from the spinal cord through an opening on each lateral side of the vertebra. It is at this exit that we have the basic problem with discs pressing on the nerve. It is usually disks pressing on nerves that cause the condition we call back pain, or sciatica. Although pains in the back and neck some times seem like they are coming from the muscles, muscles in fact are rarely the cause of severe pain. Ligaments can be another source of pain, these are considered strains. After talking to my surgeon friend Dr. Hiller about the theory of muscles causing back pain. He said; You need to look at the disks and the nerves when you do an operation. Then you see how swollen and irritated the nerves and tissue can be with back pain, it comes from the nerves being pressed by the disc.  So pain becomes our measure, you don t know what can cause some of these back pains unless you are trained in assessment of the spine. Most of the experts in the spine are Orthopedic Surgeons, and Physiatrists (Physical Medicine MD) Osteopathic Doctors (DO) and some Chiropractic Doctors (DC). Even here we have controversy, as there it times when a manipulation can help and other times when it doesn t. I wish we could just work together for the betterment of the patient and put our differences away. Just as there are many type of back pain and injuries there are many ways to treat these conditions. Let s start with the most mildest form of back tension and work our way to the worst pain. First of all every body on this planet has some sort of muscle tension. This comes from dealing with gravity. If you fight it, you loose and the result of that is muscle tension and pain. These muscle tension knots can be a source of dull pain, in the neck and shoulders are the most common areas. Sometimes after doing any heavy fiscal activity. When the muscle is contracted for an extended period, nutrients in the blood can't get in and toxins from action can't get out. This forms a chronic stress full and contracted muscle. Massage can help break the cycle, but to cure it for the long term we need to get to the core cause, the structure and body mechanics. The next tension level is muscle spasms, or cramps. These may be more severe knots in your body causing you pain. This pain can create secondary muscle holding patterns, and then you have a whole bunch of tension. Many times the intense muscle spasms are actually a protective mechanism and secondary to some sort of injury. You may have torn or injured a muscle (strain), or just as common injured a ligament (sprain), or even disc. These conditions can all cause muscle spasms and although the pain feels like it s in the muscle, it most often is referred pain coming from the nerves. The muscles can feel very sore to the touch, as well as you may have trigger points that are very tender. These are secondary conditions medical methods, Chiropractic and massage can only help the spasm temporarily. Torn muscles of the back or neck area are fairly uncommon unless you are talking about a whiplash from a car accident, or a severe football or other forms of accidents. Vertebrae misalignments, sprained or torn ligaments or discs pressing on nerves are the main causes of most back or neck pain. It is not uncommon to have referred pain when you have a pressing disc on a nerve. The nerve may be sending pain messages down the leg or arms depending on where it is. It s a common theory that the further down the pain goes the more pressure is on the nerve. We have several orthopedic ways to examine the spine to determine the problem. When pain is referred though the body it takes a very specific pattern, and the dermatomes give you the map. The dermatomes are the areas that allow us to determine which vertebra is causing the problem. Each nerve exiting out from it s specific vertebra has a mapped out area where it communicates to, sends pain, numbness or tingling. Injury to the lumbar area often causes pain in the buttocks, or it goes down the leg. On server circumstances it can reach as far down as the foot or toes, causing numbing or tingling sensations all the way down. However if you are not a doctor or working under one, you should be careful to not diagnose this type of injury. If you have more localized pain it could be that a lower back ligaments could be sprained. You need to do the orthopedic tests to determine that. With either of these injuries you can feel pain down the leg, across the foot, and ending in the toes. Even some physicians have difficulty determining weather it s a disc, a sprained ligament in the spine, or the sacroiliac joint, if you are not familiar with the orthopedic examinations. When in doubt refer to a qualified back & neck physician. Weakness in the muscles or extremities Sometimes you feel like you have lost control of your leg or arm during a back or neck injury. The muscles may feel weak or like you have very little control. This condition is indicative of a nerve being pinched. I have had patients that could not lift their leg off the table. When the nerves are pinched enough to cause this, the motor use is impaired. If this persists it could cause permanent damage. The weakness can occur in an arm, hand, leg, or foot. It could be accompanied by numbness, tingling sensation or it might not. Long term neglect of such a condition could lead to a change in the size and tone of the muscles that are affected. This muscle shrinking is called Atrophy. This does not happen too often, as most people get help before that happens. Sometimes the muscle atrophy and weakness is very obvious, but other times it s more subtle and can hardly be noticed. To me this is where prevention therapy comes into effect, in correcting the structure before it becomes a problem. This is the key to my whole therapy and fitness program. Operating at the highest level of body mechanics is one of our goals. When the injury is in the spine or the neck, that weakness indicates that a ruptured commonly called "slipped disc  is pinching a nerve severe enough to interrupt the nerve s ability to communicate with that part of the body. The whole body receives orders from the brain through the nervous system, when a ruptured disc causes intense pressure on the nerve, the electrical impulses can no longer get through. The muscles don t work at their fullest capability, for athletes this is imperative, because they want to work at the best level they can. For the rest of us it s more subtle, we may have less energy, feel a little weaker or just not be sure what is going on, even walking can be a problem with this condition. Abnormalities or diseases of the spine Lordosis (sway back) One of the most common problems of the back we see is the sway-back or sagging posture is called Lordosis. Lordosis refers to an exaggerated forward (anterior) curve of the spine. I believe its more of a postural problem rather than inherited from our parents. However there is the possibility that we inherit some of the weakness, then we copy their postures and habits later in life. (See Feldenkrais, Dychtwald, Rolf). They postulate that the body postures follow the mind patterns that we create with our personalities. We all have a small anterior curve of the lower spine, a posterior or backwards curve of the thoracic area and an anterior curve of the neck. There is a purpose for these curves. They are more shock absorbing this way and much stronger, as leverage. This is normal and desirable. I often find that many necks have what they call, a reverse curve. It s only when they get out of balance or exaggerated that they can cause problems. In my experience this leads me to believe that a chronic swayback can lead to ligament stress to the lower spine, because it s under constant stress. As well as causing the whole body to compensate, thus increasing the pressure on a specific disc or discs. Then all of a sudden one day you bend down to tie your shoes and you are knocked to the floor. Many therapists believe that a tight psoas muscles causes this Lordosis condition. Once again in my opinion the muscles are not strong enough to pull bones out of place. Specially the bones of the pelvis and lower back, which are too large. This condition usually comes from improper posture over a long period of time. Kyphosis Kyphosis is an exaggerated posterior curve of the spine. This is also common, it could happen in the mid back region sometimes called a hunchback or as a reverse curve in the neck or lumbar area. This could be an inherited structural abnormality, in its milder form. You see it passed on from parent to child, and is more common in men. The potential for weakness can be inherited and then we imitate our parents habits. It s more poor posture and lack of proper exercises that sometimes creates this condition. It s not uncommon to have no symptoms, however there are many that have muscle pain and tension. Scoliosis Scoliosis is one of the most common conditions where everyone can see severe miss-alignment of the spine. It is thought a congenital condition, I have doubts, usually passed on from mother to daughter. In my experience more women about 90%, have scoliosis compared to men. There are many degrees of scoliosis and depending on the condition, it may not even hurt. Many of us have a mild form of it. It's a condition that makes the spine twist and shift laterally in an S curve. This causes the muscles in the back to develop differently some on one side of the spine to the other. It can also in extreme cases, cause the ribs to stick out on one side, and the chest to be different too. The shoulders will appear at different heights. I treated many patients with scoliosis with different results (15 in one survey of a year). There are two types of scoliosis. One is called functional scoliosis, which means when you check the patient laying down there is no noticeable curve or it s mild. However when they stand up, it is very noticeable. With this condition I have had good to moderate success. Many patients had pain in the back, some in the shoulder, as it is in a precarious mechanical position and others even suffered in the neck. After a series of treatments more than 85% of these patients had relief of pain. Some actually changed in their postures quite noticeably. Then there where a few others that we could not help much. I even had two girls with stainless steel rods, placed in their backs because of the scoliosis, they where still having problems as does not address the core problems. Sometimes this surgery is the last resort treatment for this condition. I have also had a patient with wedge shape vertebrae, this is structural scoliosis. This condition is impossible to correct through therapy, as the vertebrae shape has grown deformed. It s like a wedge and so the body tilts sideways. Then amazingly the body tilts on the other side of the gravity line and wedges them the other direction. This type is very rare. I have only seen one patient like this in thirty years. I found that through massage and structural corrective excesses we could reduce the pull of the muscles, help re-align the ligaments and give some relief to the patients. There where a couple of patients that their scoliosis totally improved to the degree that the before and after x-rays looked like two different bodies (four out of the eight). The key is the series of therapy as well as specific, corrective exercises to re-structure the spine. Medical science is still not sure what causes scoliosis, how to prevent it, and at times difficult to treat with conventional methods. Spondyloisthesis Spondyloisthesis is a disease where one of the vertebrae is pushed anterior or posterior off the center of the spine. In other words, it s not properly aligned over the vertebrae above or below it. I have seen this condition in the clinic and can be a severe enough problem for some patients that it takes some serious therapy to help, especially if there is severe and constant pain. The vertebra could be off by one quarter to one half an inch out of alignment. This miss-alignment means that people with this condition are more susceptible to pain and injuries in this area. This can happen in the lower back, but also in the neck or mid back as well. Not a very common problem, but there are similar problems with less severity. These are vertebras out of alignment, too anterior or to posterior or even twisted. Now for the doctors that feel that misaligned vertebras are not a source of pain, Spondyloisthesis is the worst condition that demonstrates that theory, and not questionable. Just palpate around vertebrae that are severely out of alignment and you will find pain and tension all around them. The disc itself doesn't really hurt as it has very little nerves or blood flow to it. That s why cartilage injuries take longer to heal, they have less blood flow. All of these conditions can create the condition that can lead to a disc injury. Treatment for ligament or muscle tear For any injury involving muscle or ligament, we use RICE (Rest Ice Compression and Elevation) if it s in the neck elevation is relative, I would lay them down anyway. The treatment is DTF (deep transverse friction massage). This treatment was first started by a Dr. James Cyriax, an Othopedic doctor who treated many of his patients with this very specific form of massage. Careful to apply at the patients tolerance level of pain DTF can aid in the healing of strained muscles and sprained ligaments. Traction would not be a good idea at this point nor deep longitudinal massage on the lesion would both increase the tear. Massage on the other muscles in the holding pattern or that are compensating for the pain would always help, but remember, we need to get to the cause to get the best results. During the acute phase, is not the time to do structural alignment or traction to increase mobility. That needs to be done in the second phase of treatments. Diathermy (electronic heat) and ultrasound (sound waves that create heat) have some significant use in this situation, because they increase the blood flow that helps the body to heal. I prefer ice during the acute stage at least for four or five days, or as long as there is pain. Use of ice in the neck requires some patience and experience. The DTF with the ice cube is my preferred method. These are common traditional medical treatments. Even acupuncture helps during this stage, to accelerate healing. The next level of severity with this ligament injury may require seeing a doctor, for an injection. Sometimes a steroid injection into a muscle or swollen area can help break the cycle of pain. There are also proliferant injections (Glucose) sometimes called sclorosing, that help create scar tissue on ligaments, to help bind the tear and accelerate healing. Very few doctors are skilled or use this type of treatment, however it can be very effective. Traction or manipulations at this acute stage is not very productive, although I have seen improvement, at the later stages with these therapies. Of course this type of injury can happen just as easy with a sudden twist as in sports or a car accident. It can also come on over a period of years. We don t really know what causes this type of severe ligament injury. We can only guess that improper posture is a possible cause and that over a period of time we have put unusual stress and pressure on this tissue. Because the ligaments are stressed by misalignments, they can exert more pressure on the whole structure, until one day it presses on the nerve severely enough to cause us the pain, it may get worse and cause disc problems as well. Which can happen bending over or even sleeping wrong. It can seem to come on fast. The mid back or thoracic area of the spine. This area protects the chest cavity and is designed like a cage with the spine and the ribs forming its structure. Consequently this area has less movement because of the structure. There are less injuries to the thoracic area than the neck and lower back. Often the pain we feel in the upper back is often coming from the neck. There are some injuries to this area, if you are pre-disposed to stress and tension. Or you may have some scoliosis there, which can tear some of the muscles with a sudden move. Usually pain in this area if it is a muscle tear will hurt with breathing. Sometimes we call it having a rib out. Rib heads don t move too easy unless you tore some ligaments there or have a weak link. In a car accident you could hurt any area that has unusual tension, or scar tissue from an old injury, and that could be ligament and disc injuries. You can also hurt this area by lifting something heavy and twisting. You may feel a sharp pain and later it becomes a dull ache. This could last weeks, if you rest for a couple of weeks and it doesn t get better, that s not going to help it. If the rest does not help, it can be treated with manipulation, sometimes a few treatments help. If you can find the source of the lesion a muscle tear may be treated with DTF with some success. Then again medical intervention may be needed in the from of injections. Once again depending on the cause of the pain and the type of injury the treatment needed is important to know. Traction is not very effective for the thoracic area. The low back The mysterious low back, it s a very controversial area of the body. Some doctors, think it s totally physical, others mental, some say stress, some say it s because we walk upright. Kind of silly, that this back that has taken thousands of years to evolve would have any weaknesses. I don t know, how could it become such a problem for modern man. What did the cavemen do when their back gave them trouble, or did it? No one really knows. Also why do some people have horrible x-rays (misalignments that look like they should be dead) and have no symptoms. Then again you have someone with a normal looking x-ray with lots of pain, this is the mystery. Some doctors and therapists like myself have dedicated our life to understanding this mystery. This to me the key, understanding is not important. Helping is, and you never know from one individual to another what is going to help. We are all at a loss and sometimes we have to experiment, with conservative methods and then when all else fails look at anything else that may help. That emotional or mental stress contributes to pain, is just being understood. The body can create it s own cortisone, as well as endorphins (Morphine like compounds), that are stronger than anything we make in the laboratory. What causes the body to get out of balance to the point that we have this kind of pain with no noticeable injury? We could ask why? forever and it does not matter. The key to me is, how to best help these people that suffer. We know we need to work together as no human has all the answers. I have had great success with people that have been given up on by conventional medicine. On the other hand I have seen people that have been helped by conventional medicine that gave up on natural healing methods. We have the best of both worlds, and if we continue fighting as to who is right, or what the best treatment is, we are missing the point. The key is integrated medicine, combining the best of medical science with natural healing and nutrition. The holistic way seems to be the best way to help the unusual or chronic problems. Low back injuries The most common low back injury comes from picking up something too heavy. It can also come on gradual, overuse, too much bending over on the job, poor posture all your life. You can get a low back injury in an auto accident as well. In fact I have seen hundreds of auto accident patients and the thing I noticed, is every individual even though suffered similar accidents (Rear ended) not only had different areas where they where injured, they also had different symptoms and pain. The weak link is the one that suffers when you push the body beyond the limits of what you have trained it for, or prepared for. If you have a chronic area of tension, you can actually have a weak link. Then the muscle, if it starts there, put stress on the joint, that it attaches to. The joint, if it has ligaments and cartilage or a disc, then suffers this stress, it s a chain reaction. We are talking about structural stress, not mental. Well, add mental stress to it along with some physical stress and we have a weak link, that can succumb to injury. Sacral ligaments, sometimes get injured as well. Take a simple fall on your butt, how many of us have fallen on that maximus, everyone. The many times we fall as children we seem to heal fast, but can cause future injuries, or potential problems for later in life. These mass of ligaments at the base of the spine that connect the sacrum to the pelvis can create similar shooting pain that the disc creates. Muscles very rarely are the problem in low back pain unless it s overuse like I mentioned. They go into spasm as a protective mechanism not as the source of the problem. Disc injuries The commonly referred slipped disc, is actually either a bulging disc or a herniated disc. A bulging disc means that it s sticking out of it s normal space. A herniated disc, means the disc, outer shell has torn, and let out the softer material in the middle. This compresses the nerve and can cause pain locally, in the buttocks or all the way down the leg. Of course if you get hit in a football game from the back, also notice there are no pads there, it hurts and you can not only injure ligaments and muscle, but you can rupture a disc. Over use, can cause muscle holding and injury to the muscle and ligament tissues. If this continues, you bet the disc can be next. I have treated many carpenters for low back problems. For those of you who have built a house, you know how hard this work is, from bending over, to lifting walls, or caring heavy packs of shingles up a ladder. This type of work just wares the body down. The worst condition of a disc injury can cause some paralysis. You may not be able to move, or even walk when you have this kind of back injury. The symptoms may be different in each situation, but in this severe condition it s unmistakable. Just lowering your head can cause pain in that area. Sometimes coughing can cause worse pain, as well (these are two tests we do to determine if it s a disc). This is because of the connection of the dura matter in the spine that is all connected through the spinal column. When the disc, bulges which can be varying levels of severity and pain. Or when it is ruptured the soft matter flows out and presses on the nerve. As the nerve gets more irritated from the pressure and it rubbing on it constantly, it gets harder and harder to help this condition with conventional treatments. This is why we recommend that when you first hurt your back you get medical attention right away. If you have ruptured a disc, the best conventional treatment is using anti-inflammatory drugs, sometimes a muscle relaxant may be needed or even pain medication. I have also used lots of ice, I m talking for two or three days in a row, all day long. Then rest in bed and let that irritation of the nerve calm down. A week in bed can often control, or even correct this condition, and I can attest personally to this. If you neglect getting help or rest and continue to irritate and cause secondary muscle holding patterns it can last a year or more at the extreme. When severe and pushing to one side you can see patients listing (leaning to one side) when the disc is injured. Eventually the body re-absorbs the disc matter in the tissue, if it s torn, but can take a long time. However I believe that you have a weak link after that injury. Not stronger like in a bone fracture, as I have re-injured the same disc three times. It s not always successful for all disc injuries, but some manipulations seem to help and ligaments as well as some muscle injuries. We think that by aligning the vertebras it takes pressure of the ligaments, muscles or discs and allows the body to improve. Maybe we tear improperly formed scar tissue and it heals correctly. However, if after ten or more adjustments you don t get any relief, try something else (Cyriax). That may not be the problem nor the solution. There are several ways to determine if it s a disc. First see a doctor, they will do some tests. Some of the most common ones are; They ask if it hurts when you cough. Also they will have you lower your head, if both of these are positive, its very likely they will test your foot or knee reflexes. Sometimes they may have you stand and lean into the area that hurts. This may not be necessary, if you are listing (leaning to one side) as this is very positive symptom of a disc injury. A disc can be very dangerous if it impairs your nerves that help with your bladder or bowel function. This can be serious, this is not too common but does happen, it s best to be safe. Pain caused in the sex organs can be very serious as well and should be looked at by a doctor. Bernard Portner MD (Physiatrist in Honolulu) who I worked for, showed me that there was a place for drugs and with some cases of bursitis especially of the shoulder it s the only treatment that is any good. The key is to use them with care, and not just to appease a chronic condition. Also, use of injections need to be followed with the caution to stop training. As the tissue can get weakened with steroids and can get injured worse, if the person does not stop. If they are over used it can cause the tissue to deteriorate and make the problem worse. I became a believer of drugs after spending most of my twenty years previous being against them. We have talked about injections because at times it is necessary to resort to whatever it takes to get better. To me these along with surgery should be a last resort. Treatment of disc injuries The treatments for a disc injury vary as much as doctors. Having seen hundreds upon hundreds of back patients in a physical therapy clinic and during my 30 years as a therapist, I know that this conservative approach works. Sometimes this condition gets better without doing anything but rest. Some therapies may actually aggravate the condition more. Therapies involving twisting or adjustments may hurt more than help during the acute state. Massage not performed properly can also aggravate the condition. Traction, trigger point therapy and medical massage properly applied, with knowledge and at the right time can certainly help (See the works of Dr. James Cyriax ). Sometimes injections of a steroid with analgesic medicine is needed to break the pain cycle. This is called a epidural injection. Then there are some new injections of Papin (papaya enzyme) that help dissolve the disc and get the patient back into recovery. Of course, we always combined manual therapy with these injections as well, sometimes a nerve block is needed. I have seen sclorosing (Injection of glucose-or dextrose create scar tissue and stabilize a weak disc). Other times it takes traction, in the secondary phase of treatments and the PT (Physical Therapists) can give you great exercises to improve your back condition, we still used massage during the traction phase. Acupuncture can sometimes help, but if it is structural it needs to get corrected with a structural treatment. Acupuncture is more for pain control, energy improvement and increased circulation, some professionals can use it as a powerful analgesic. Some herbs have even healed some disc problems, you just never know what is going to work. The key again, is to have an open mind and to realize that whatever it takes to heal, is what it takes. Surgery should always be the last recourse. Even my surgeon friends say the same thing. They are very conscientious these days. There are plenty of people that really need surgery. Most doctors are very conservative, and that means concerned as well as careful. They try everything else first. You can t be in this profession and not care. There is a new procedure for the disc, it called IDET (Intra disc electronic therapy). What they do in insert a wire into the spine with a little camera, like they do with arthroscopy knee surgery, and it cauterizes the ruptured disc causing it to close up. This is a new procedure and there are only a handful of doctors that do this It s less evasive than conventional surgery, that fusses your spine, because unfortunately even then, you never know if the problem will be corrected. This is another reason we don t understand back problems, you would think once you fix it, the pain goes away. Well that is the mystery of the spine, as some doctors think, it s all in our mind. References and recommended books; James Cyriax MD Orthopedic Medicine Volume I , II Wilkins Co. Baltimore MD 1977 Paul Vinger MD. Sports injuries , PSG Publishing : Littleton MA 1981 Stanley Hopperfield- Physical Examination of the spine and extremities Ben Benjamin Listen to your pain Penguin Books 1984 Ken Dychtwald, Body Mind. Published in Britain , Wildwood house 1978 For information or questions call or e-mail; Othon Molina, Ph.d.c, LMT P.O. Box 1231 Kamuela, HI 96743 Cell: (808) 895-2688 www.molinamassage.com
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