Living with Chronic Conditions and Pain

Living with chronic conditions and pain presents a multifaceted challenge, impacting not only physical well-being but also mental health, relationships, and overall quality of life. This exploration delves into the complexities of managing chronic pain, offering insights into effective coping mechanisms, stress reduction techniques, and the crucial role of mental health support. We will examine the various types of chronic pain, their impact on daily life, and the resources available to navigate these difficulties.

From understanding the physiological effects of chronic pain to exploring the psychological and emotional consequences, we aim to provide a comprehensive overview of this pervasive issue. The journey through chronic pain often involves navigating complex medical treatments, building resilience, and fostering a strong support network. This exploration will illuminate pathways towards a more manageable and fulfilling life for those living with chronic conditions and pain.

Understanding Chronic Pain and Conditions

Living with chronic pain significantly impacts daily life, affecting physical, emotional, and social well-being. It’s a complex issue with varied causes and presentations, requiring a multifaceted approach to understanding and management. This section explores the nature of chronic pain, its diverse manifestations, and the challenges it presents to individuals and their support systems.

The Impact of Chronic Pain on Daily Life Activities

Chronic pain disrupts the routine and rhythm of daily life. Simple tasks, once effortless, can become monumental challenges. Personal care, such as showering or dressing, can be excruciating. Household chores, work responsibilities, and leisure activities may become impossible or require significant modifications. Sleep disturbances are common, further exacerbating fatigue and pain levels, creating a vicious cycle.

The constant presence of pain can lead to decreased mobility, social isolation, and depression. For example, someone with chronic back pain might struggle to walk their dog, participate in their favorite hobbies, or even maintain their professional role. This constant struggle can lead to a significant decline in quality of life.

Types of Chronic Pain Conditions and Their Common Symptoms

Chronic pain encompasses a broad spectrum of conditions, each with its own set of symptoms. Fibromyalgia, for instance, is characterized by widespread musculoskeletal pain accompanied by fatigue, sleep disturbances, and cognitive difficulties (often referred to as “fibro fog”). Arthritis, an inflammatory condition affecting joints, presents with pain, stiffness, swelling, and reduced range of motion. Neuropathic pain, originating from damage to the nervous system, often manifests as burning, tingling, shooting, or stabbing pain.

The intensity and nature of symptoms vary greatly among individuals and even within the same individual over time. These conditions often coexist, further complicating diagnosis and treatment.

Challenges Faced by Individuals Living with Chronic Pain and Conditions

Individuals living with chronic pain face a multitude of challenges. These include the physical limitations imposed by the pain itself, the emotional toll of constant discomfort and uncertainty, and the financial burden of medical expenses and lost income. Accessing appropriate and effective healthcare can be difficult, with long waiting lists, limited specialist availability, and the need to navigate a complex healthcare system.

Furthermore, the subjective nature of pain makes it challenging to diagnose and treat effectively, often leading to frustration and feelings of being misunderstood. The lack of a “cure” for many chronic pain conditions adds to the sense of hopelessness and despair.

The Impact of Chronic Pain on Relationships and Social Interactions

Chronic pain significantly impacts relationships and social interactions. The constant need for support, the limitations on physical activities, and the emotional burden of living with pain can strain relationships with family, friends, and partners. Social withdrawal is common, leading to isolation and loneliness. Individuals may find it difficult to participate in social events or maintain previous levels of engagement.

The unpredictability of pain can make it challenging to plan activities or commit to social engagements. Misunderstandings from those who do not experience chronic pain can further exacerbate feelings of isolation and frustration. For instance, a person with chronic migraines may have to cancel social events at the last minute due to a sudden onset of severe headache, leading to strained relationships if their struggles are not fully understood.

Impact of Three Different Chronic Pain Conditions on Daily Life

Condition	Physical Limitations	Emotional Impact	Social Impact
Fibromyalgia	Fatigue, widespread musculoskeletal pain, reduced mobility	Depression, anxiety, difficulty concentrating	Social withdrawal, difficulty maintaining relationships
Osteoarthritis	Joint pain, stiffness, swelling, reduced range of motion	Frustration, anger, feelings of helplessness	Limited participation in activities, dependence on others
Neuropathic Pain	Burning, tingling, shooting pain, numbness	Irritability, anxiety, sleep disturbances	Difficulty concentrating, reduced ability to work or socialize

Coping Mechanisms and Strategies

Living with chronic pain and conditions requires a multifaceted approach to management. Effective coping involves a combination of medical interventions, lifestyle adjustments, and emotional support. This section explores various strategies individuals can utilize to navigate the challenges posed by chronic pain and improve their overall quality of life.

Effective Pain Management Techniques

Pain management is a highly individualized process. What works for one person may not work for another. A collaborative approach with healthcare professionals is crucial to develop a personalized plan. Medication, often prescribed by a doctor, plays a significant role for many, ranging from over-the-counter analgesics to stronger prescription medications. Physical therapy, employing techniques like stretching, strengthening exercises, and range-of-motion improvements, helps to improve physical function and reduce pain.

Alternative therapies, such as acupuncture, massage therapy, and mindfulness-based techniques, may offer additional relief and support for some individuals. It’s important to note that the effectiveness of these therapies varies, and a trial-and-error approach might be necessary to find the best combination for an individual’s specific needs.

Personal Stories Illustrating Successful Coping Strategies

Sarah, a 45-year-old teacher diagnosed with fibromyalgia, found significant relief through a combination of medication, regular yoga practice, and a strong support group. Initially overwhelmed by the constant pain, she discovered that a consistent yoga routine helped improve her flexibility and reduce muscle tension. The support group provided a safe space to share her experiences and learn coping strategies from others.

Similarly, Mark, a 60-year-old retired carpenter struggling with osteoarthritis, found that a personalized exercise plan created by his physical therapist, coupled with regular meditation, significantly improved his mobility and reduced his pain levels. He discovered that even small, consistent actions made a considerable difference in his overall well-being. These examples highlight the importance of finding a personalized approach that incorporates various strategies to effectively manage chronic pain.

The Importance of a Strong Support System

Having a strong support system is invaluable for individuals living with chronic conditions. This network can provide emotional support, practical assistance, and a sense of community. Family, friends, support groups, and healthcare professionals all play crucial roles. Sharing experiences with others who understand the challenges of living with chronic pain can help alleviate feelings of isolation and provide a sense of hope.

The emotional burden of chronic pain can be substantial, and a supportive network can help individuals cope with the psychological impact. Open communication with loved ones is key to ensuring they understand the individual’s needs and can provide appropriate support.

Resources for Individuals Living with Chronic Pain

Finding reliable information and support is essential for navigating the complexities of chronic pain. The following resources offer valuable information, support groups, and access to healthcare professionals specializing in pain management:

• The National Institutes of Health (NIH): Provides comprehensive information on various chronic pain conditions and treatment options.
• The Arthritis Foundation: Offers resources and support for individuals with arthritis and other rheumatic diseases.
• The American Chronic Pain Association: Provides education, advocacy, and support for people living with chronic pain.
• The Mayo Clinic: Offers detailed information on various health conditions, including chronic pain, and treatment options.

Stress and Anxiety Management

Living with chronic pain often creates a vicious cycle. The pain itself is stressful, leading to anxiety, which in turn can worsen pain perception and overall well-being. Understanding this connection is crucial for effective management. This section explores strategies to mitigate stress and anxiety associated with chronic pain conditions.

The Interplay Between Chronic Pain, Stress, and Anxiety

Chronic pain significantly impacts the body’s stress response system. The constant discomfort triggers the release of stress hormones like cortisol, leading to heightened anxiety and potentially impacting sleep, mood, and immune function. This persistent activation of the stress response can exacerbate pain sensations, creating a feedback loop where stress intensifies pain, and pain increases stress. This cycle can lead to depression, further complicating the management of the chronic pain condition.

For example, a person with fibromyalgia might experience heightened anxiety before a physically demanding activity, anticipating the pain that will likely follow. This anticipatory anxiety can then intensify the pain experienced during and after the activity.

Stress Management Techniques

Several techniques can effectively manage stress associated with chronic pain. These techniques aim to calm the nervous system and reduce the body’s stress response.Deep breathing exercises, such as diaphragmatic breathing, involve slow, deep breaths that activate the parasympathetic nervous system, responsible for the “rest and digest” response. This counteracts the “fight or flight” response triggered by stress. Progressive muscle relaxation involves systematically tensing and releasing different muscle groups, reducing muscle tension and promoting relaxation.

Meditation, focusing on the present moment without judgment, helps to quiet the mind and reduce racing thoughts often associated with anxiety and pain.

Mindfulness Practices for Chronic Pain Management

Mindfulness practices, such as meditation and mindful movement, offer a powerful approach to managing chronic pain-related stress and anxiety. Mindfulness encourages focusing on the present moment, observing sensations without judgment. This helps to reduce the emotional reactivity often associated with pain. For instance, instead of reacting with fear or frustration to a pain flare-up, a mindful approach involves acknowledging the pain sensation without judgment, observing it as it is, and accepting it without resistance.

This detachment can lessen the emotional intensity of the experience and reduce the overall stress response. Mindful breathing exercises can also help individuals to regulate their physiological response to pain.

Yoga and Tai Chi for Stress Reduction

Yoga and Tai Chi combine physical postures, breathing techniques, and meditation, offering a holistic approach to stress reduction in individuals with chronic pain. The gentle movements in yoga and Tai Chi improve flexibility, strength, and balance, reducing physical discomfort. The mindful movement and controlled breathing inherent in these practices activate the parasympathetic nervous system, counteracting the stress response. Studies have shown that regular practice of yoga and Tai Chi can significantly reduce pain intensity, improve mood, and enhance sleep quality in individuals with chronic pain conditions.

For example, a study published in the journal Pain showed that yoga significantly reduced pain intensity and improved functional capacity in patients with chronic low back pain.

Comparison of Stress Reduction Techniques

Technique	Description	Benefits	Potential Drawbacks
Deep Breathing	Slow, deep breaths focusing on diaphragmatic breathing.	Reduces heart rate, lowers blood pressure, promotes relaxation.	May require practice to master the technique; may not be effective for severe anxiety.
Progressive Muscle Relaxation	Systematically tensing and releasing muscle groups.	Reduces muscle tension, promotes relaxation, improves sleep.	Can be time-consuming; may not be suitable for individuals with limited mobility.
Mindfulness Meditation	Focusing on the present moment without judgment.	Reduces stress, improves emotional regulation, enhances self-awareness.	Requires regular practice; may initially be challenging to quiet the mind.

Depression Support Resources

Living with chronic pain often significantly impacts mental health, and a strong correlation exists between chronic pain and depression. Understanding this connection is crucial for effective management of both conditions. Many individuals experiencing chronic pain also develop depression, highlighting the importance of integrated treatment approaches.The link between chronic pain and depression is complex and bidirectional. Chronic pain can lead to depression through several pathways, including the disruption of normal sleep patterns, reduced social interaction, and feelings of hopelessness and helplessness resulting from persistent discomfort.

Conversely, depression can exacerbate pain perception, making the pain feel more intense and debilitating. This cyclical relationship emphasizes the need for comprehensive support addressing both the physical and emotional aspects of the condition.

Signs and Symptoms of Depression in Individuals with Chronic Pain

It’s important to recognize that depression in individuals with chronic pain may manifest differently than in those without. Symptoms can be subtle and easily overlooked, often masked by the already present pain. These symptoms might include persistent sadness or low mood, loss of interest or pleasure in activities once enjoyed, changes in appetite or sleep patterns (either increased or decreased), fatigue or low energy, feelings of worthlessness or excessive guilt, difficulty concentrating, and recurrent thoughts of death or suicide.

It’s crucial to note that the presence of several of these symptoms, even at a low intensity, warrants professional evaluation. The experience of chronic pain itself can lead to some of these symptoms, so it’s important to distinguish between the normal emotional responses to pain and a clinical diagnosis of depression.

Available Depression Support Resources

Several resources are available to help individuals cope with depression alongside chronic pain. These resources often work best in conjunction with one another, offering a holistic approach to management.Therapy, particularly cognitive behavioral therapy (CBT) and other evidence-based approaches, can be highly effective. CBT helps individuals identify and challenge negative thought patterns and develop coping strategies for managing pain and depression.

It teaches techniques for managing pain-related thoughts and behaviors, and for improving mood regulation.Support groups provide a safe and supportive environment for individuals to share their experiences, learn coping mechanisms, and feel less isolated. Connecting with others facing similar challenges can be incredibly validating and empowering. These groups often offer peer-to-peer support and shared strategies for navigating the complexities of chronic pain and depression.Medication, such as antidepressants, may be prescribed by a physician or psychiatrist to help manage depressive symptoms.

Antidepressants can help regulate mood and improve sleep, which can indirectly impact pain perception. It is important to discuss any potential medication side effects and interactions with other medications with a healthcare professional. The choice of medication and dosage is always personalized based on individual needs and responses.

Importance of Early Intervention

Early intervention for depression in individuals with chronic pain is paramount. Untreated depression can worsen pain perception, lead to further disability, and increase the risk of suicide. Early identification and treatment of depression can significantly improve the overall quality of life and reduce the long-term impact of both conditions. Seeking help early allows for the implementation of effective strategies before the depression becomes deeply entrenched, making treatment more challenging.

The sooner intervention begins, the better the chances of managing both the pain and the depression effectively and improving overall well-being.

Mindfulness Practices for Pain Management

Mindfulness, the practice of paying attention to the present moment without judgment, offers a powerful approach to managing chronic pain. By shifting focus away from the discomfort and towards the present experience, individuals can reduce the intensity of pain perception and improve their overall well-being. This involves cultivating awareness of bodily sensations, thoughts, and emotions without getting caught up in negative reactions.

This approach doesn’t aim to eliminate pain entirely but to change the relationship with it, fostering a sense of acceptance and reducing suffering.Mindfulness techniques help manage pain perception by altering the brain’s response to painful stimuli. Studies have shown that regular mindfulness practice can increase activity in brain regions associated with pain regulation and decrease activity in areas linked to emotional reactivity to pain.

This leads to a decrease in the perceived intensity and unpleasantness of pain, allowing individuals to experience a greater sense of control and calm. The focus shifts from the pain itself to the broader context of the present moment, creating a sense of detachment and reducing the emotional distress often associated with chronic pain.

Guided Meditation Scripts for Pain Reduction

Guided meditation can be a particularly effective tool for pain management. The following scripts provide examples of how to use this technique. Remember to find a quiet space, sit or lie down comfortably, and close your eyes.

Guided Meditation Script 1: Focusing on the Breath

Bring your attention to your breath. Notice the sensation of the air entering and leaving your nostrils. Feel the rise and fall of your chest or abdomen. If your mind wanders, gently guide it back to your breath. Focus on the sensation of each inhale and exhale, noticing the coolness of the air as it enters and the warmth as it leaves.

Allow yourself to simply observe your breath without judgment, noticing any changes in its rhythm or depth. If you feel pain, acknowledge it without resisting it. Simply observe the sensation as it arises and passes, like a cloud in the sky.

Guided Meditation Script 2: Body Scan Meditation

Begin by bringing your attention to your body, noticing any sensations without judgment. Slowly bring your awareness to your toes, feeling any sensations of pressure, temperature, or tingling. Move your attention slowly upwards, through your feet, ankles, calves, knees, thighs, hips, and so on. As you scan your body, notice any areas of tension or discomfort. Acknowledge these sensations without judgment.

Simply observe them as they are, without trying to change them. Continue this scan until you have brought your awareness to the top of your head. Then, slowly bring your awareness back to your breath, and gently open your eyes when you are ready.

Benefits of Body Scan Meditation for Individuals with Chronic Pain

Body scan meditation is particularly beneficial for individuals with chronic pain because it encourages a non-judgmental awareness of bodily sensations. By systematically bringing attention to different parts of the body, individuals can learn to identify and observe pain without amplifying it through fear or resistance. This practice cultivates a sense of embodied awareness, fostering a more nuanced understanding of the body’s sensations and promoting a sense of connection and acceptance.

Regular practice can lead to improved pain tolerance, reduced anxiety related to pain, and a greater sense of body awareness.

Comparison of MBSR and ACT for Pain Management

Mindfulness-Based Stress Reduction (MBSR) and Acceptance and Commitment Therapy (ACT) are both evidence-based approaches that incorporate mindfulness practices for pain management, but they differ in their focus. MBSR emphasizes cultivating mindfulness to reduce stress and improve overall well-being, indirectly impacting pain perception. ACT, on the other hand, focuses on accepting difficult experiences, including pain, and committing to valued actions despite discomfort.While both approaches use mindfulness techniques, MBSR primarily aims to reduce the emotional distress associated with pain through cultivating present moment awareness and self-compassion.

ACT goes further by encouraging individuals to identify their values and take actions aligned with those values, even in the face of chronic pain. Essentially, MBSR helps manage the emotional response to pain, while ACT helps manage the behavioral response. Both approaches have demonstrated effectiveness in reducing pain intensity and improving quality of life for individuals with chronic pain.

Mental Health Advocacy and Resources

Living with chronic pain and conditions often presents significant mental health challenges. The constant physical discomfort, limitations on daily activities, and the uncertainty surrounding the future can contribute to a range of mental health issues, including depression, anxiety, and post-traumatic stress disorder (PTSD). Understanding the interconnectedness of physical and mental health is crucial for effective management and support.

Challenges in Accessing Mental Healthcare, Living with chronic conditions and pain

Individuals with chronic pain frequently face obstacles in accessing appropriate and timely mental healthcare. These challenges include difficulties in finding healthcare providers who understand the complexities of chronic pain and its impact on mental well-being. Many providers lack specialized training in managing the mental health needs of this population. Furthermore, the high cost of mental healthcare, coupled with insurance limitations and navigating complex healthcare systems, can create significant barriers to care.

The stigma associated with mental illness also plays a role, preventing some individuals from seeking help, even when they are experiencing significant distress. The lack of integrated care models, where physical and mental health needs are addressed concurrently, further complicates the situation.

The Role of Mental Health Advocacy Groups

Mental health advocacy groups play a vital role in supporting individuals with chronic pain by raising awareness about the prevalence of mental health issues within this population. They advocate for increased access to mental healthcare services, including affordable and accessible treatment options. These groups work to educate healthcare providers and the public about the importance of integrated care and the specific mental health needs of individuals with chronic pain.

They provide resources, such as support groups, educational materials, and online communities, that foster a sense of connection and shared understanding among those affected. Moreover, they advocate for policy changes that promote better access to care and reduce the financial burden associated with treatment. Advocacy groups also provide crucial support to individuals in navigating the healthcare system and finding appropriate resources.

Available Mental Health Resources and Services

A range of mental health resources and services are available to individuals with chronic pain. These include individual and group therapy, medication management, and evidence-based treatments such as Cognitive Behavioral Therapy (CBT) and mindfulness-based interventions. Many hospitals and clinics offer specialized pain management programs that integrate mental health services. Online platforms provide access to telehealth services, making mental healthcare more accessible for individuals in remote areas or with mobility limitations.

Support groups, either in-person or online, offer a safe space for individuals to connect with others who share similar experiences, reducing feelings of isolation and providing valuable peer support. Self-help resources, such as books, websites, and apps, provide information and strategies for managing mental health challenges associated with chronic pain.

Organizations Advocating for the Mental Health Needs of Individuals with Chronic Conditions

Finding appropriate support is crucial. Here are some examples of organizations that advocate for the mental health needs of individuals with chronic conditions: The list is not exhaustive, and availability varies by region.

• The American Chronic Pain Association: Offers resources and support for individuals with chronic pain, including information on mental health resources.
• The National Alliance on Mental Illness (NAMI): Provides education, support, and advocacy for individuals and families affected by mental illness, including those with chronic pain.
• The Arthritis Foundation: Offers resources and support for individuals with arthritis, including information on managing the mental health challenges associated with the condition.
• The Crohn’s & Colitis Foundation: Provides resources and support for individuals with inflammatory bowel disease, addressing the mental health impact of these conditions.
• The National Fibromyalgia Association: Offers resources and support specifically for those with fibromyalgia, acknowledging the strong link between fibromyalgia and mental health conditions.

Therapy and Counseling Options

Living with chronic pain often involves a complex interplay of physical sensations and emotional responses. Therapy plays a crucial role in addressing both aspects, helping individuals develop effective coping strategies and improve their overall well-being. Different therapeutic approaches offer unique benefits, and finding the right fit is essential for successful management.Therapy offers a safe and supportive space to process the emotional challenges associated with chronic pain, such as frustration, anger, and depression.

It also provides tools and techniques to manage pain more effectively, reduce stress, and improve quality of life. The benefits extend beyond symptom management, fostering resilience and empowering individuals to live more fulfilling lives despite their condition.

Cognitive Behavioral Therapy (CBT) for Chronic Pain

CBT focuses on identifying and changing negative thought patterns and behaviors that contribute to pain experience and disability. It helps individuals understand the connection between their thoughts, feelings, and actions, and develop more adaptive coping strategies. For example, a person might learn to challenge catastrophic thinking (“This pain means I’ll never be able to work again”) and replace it with more realistic and balanced perspectives.

CBT techniques, such as relaxation exercises and activity scheduling, can also help manage pain and improve functional capacity. Studies have shown CBT to be effective in reducing pain intensity, improving mood, and increasing participation in daily activities among individuals with chronic pain conditions.

Dialectical Behavior Therapy (DBT) for Chronic Pain and Emotional Dysregulation

DBT is particularly helpful for individuals experiencing intense emotional reactions to chronic pain, such as emotional dysregulation, self-harm, or suicidal ideation. It emphasizes the acceptance of difficult emotions alongside the development of skills to manage them effectively. DBT incorporates mindfulness practices, distress tolerance techniques, and interpersonal effectiveness skills, empowering individuals to cope with overwhelming emotions and improve their relationships.

For example, a person might learn to identify and regulate emotional triggers related to pain, preventing escalation into destructive behaviors. Research suggests DBT can be beneficial in reducing self-destructive behaviors and improving emotional regulation in individuals with chronic pain and comorbid mental health conditions.

Benefits of Seeking Professional Therapy

Seeking professional therapy offers numerous benefits for individuals managing chronic pain and related mental health conditions. Therapy provides a structured approach to address the emotional and psychological aspects of chronic pain, often overlooked in solely medical treatments. A therapist can offer personalized guidance, support, and evidence-based techniques to manage pain, improve coping skills, and enhance overall well-being. Therapy can lead to reduced pain intensity, improved mood, increased functional capacity, and a greater sense of control over one’s life.

Developing Coping Mechanisms and Improving Quality of Life Through Therapy

Therapy equips individuals with practical coping mechanisms to navigate the challenges of chronic pain. This may involve learning relaxation techniques (such as progressive muscle relaxation or meditation), developing strategies for managing stress and anxiety, and improving communication skills to effectively express needs and concerns to family, friends, and healthcare providers. By addressing both the physical and emotional aspects of chronic pain, therapy can significantly improve quality of life, enabling individuals to participate more fully in work, social activities, and personal pursuits.

Questions to Ask a Therapist

Choosing the right therapist is crucial for effective treatment. Before starting therapy, it’s helpful to have a clear understanding of the therapist’s approach, experience, and qualifications. Consider asking these questions:

• What is your experience treating individuals with chronic pain and related mental health conditions?
• What therapeutic approaches do you use, and how do they align with my needs and preferences?
• What is your approach to managing pain and improving coping skills?
• What are the potential risks and benefits of therapy for my specific condition?
• What is your fee structure, and what insurance plans do you accept?
• What is your cancellation policy?

Ultimately, living well with chronic conditions and pain requires a holistic approach encompassing medical management, psychological support, and proactive self-care. By understanding the intricate interplay between physical pain, mental health, and social well-being, individuals can develop personalized strategies to navigate their challenges. The journey is demanding, but with the right resources, support, and resilience, a fulfilling life is attainable despite the persistent presence of chronic pain.

FAQ Summary: Living With Chronic Conditions And Pain

What are some common misconceptions about chronic pain?

A common misconception is that chronic pain is always easily visible or understood by others. It’s also frequently misunderstood as solely a physical problem, neglecting its significant psychological impact. Another misconception is that those with chronic pain are simply exaggerating their symptoms.

How can I find a doctor who specializes in chronic pain management?

You can start by asking your primary care physician for a referral. You can also search online directories of pain specialists, such as those provided by professional medical organizations. Look for doctors specializing in pain medicine or anesthesiology with experience in chronic pain management.

Is chronic pain always accompanied by depression or anxiety?

While a strong correlation exists between chronic pain and mental health conditions like depression and anxiety, it’s not always the case. However, the persistent discomfort and limitations imposed by chronic pain significantly increase the risk of developing these conditions.

Can exercise help manage chronic pain?

Yes, appropriate exercise can be beneficial. It’s crucial to consult with a healthcare professional or physical therapist to develop a safe and effective exercise plan tailored to your specific condition and limitations. Low-impact activities like swimming, walking, or yoga are often recommended.