Biomechanical Analysis of Selected Principles
of Hip Joint Protection
Donald A. Neumann
This review article discusses the role of the hip ab-
ductor muscles in the generation offorces at the hip
joint. The biomechanical rationale behind selected
clinical principles of hip joint protection for the pa-
tient with hip osteoarthritis is discussed. These prin-
ciples are based primarily on the benefit of reducing
the magnitude of hip abductor muscle forces during
walking. The specific hip joint protection principles
that are analyzed are loss of body weight, walking
with an antalgic limp, the use of a cane, proper
methods of load carriage, and the reasons for cer-
tain orthopedic surgeries. The reduction of these
myogenic hip joint forces for the patient with a pain-
ful hip andlor hip with arthritis should be consid-
ered an important component of the clinical man-
agement of the hip.
This article describes the biomechanical function of
the hip abductor muscles with a focus on their role
in the generation of hip joint forces. A biomechani-
cal appreciation of the function of this muscle group
will provide a rational basis for many hip joint pro-
tection principles recommended by health profes-
sionals who treat patients with hip osteoarthritis.
THE FUNCTION OF THE
HIP ABDUCTOR MUSCLES
An obvious function of the hip abductor muscles
(HAM] is to produce a hip abduction moment (or
Portions of this work were supported through a Clinical Investi-
gators Grant from the National Arthritis Foundation.
Donald A. Neumann, PhD, PT, is an Assistant Professor, Physi-
cal Therapy Department, Marquette University, Milwaukee, Wis-
consin.
Submitted for publication March 13, 1989; accepted November
11, 1989.
0 1989 by the Arthritis Health Professions Association.
146
torque]. This moment causes a potential for femur
rotation in the frontal plane about an axis oriented in
the anterior-posterior direction through the head of
the femur. According to an anatomical model de-
scribed by Dostal and associates [l],the gluteus me-
dius, gluteus minimus, and the tensor fascia lata
have the most favorable line of pull for hip abduc-
tion.
To appreciate fully the functional role of the HAM,
the muscles should be considered from a close-
chained perspective, i.e., when the lower limb is in
contact with the ground and the pelvis and trunk are
free to rotate about the femoral head. This situation
occurs during walking, since when one limb remains
in contact with the ground (in the stance phase], the
other advances forward (in the swing phase). There-
fore, the stance limb (and hip) experience a time of
single-limb support resulting in a natural tendency
for the pelvis and trunk to drop towards the side of
the swinging limb. A large component of the hip
joint forces that occur during single-limb support are
produced by HAM contraction that stabilizes the
pelvis and trunk in the frontal plane 121. Figure 1A
shows a simplified version of the major factors in-
volved with stability of the pelvis and trunk when
the right hip is in single-limb support [3]. For stabil-
ity about a right hip (as in Figure lA], a counter-
clockwise hip moment (i.e., the product of the HAM
force times an internal moment arm (D) must
equal a clockwise hip moment [i.e., the body weight
(BW] times an external moment arm (DJ. This
frontal plane equilibrium can be expressed as an
equation abbreviated as HAM x D = BW X D1. This
equation represents a static (versus dynamic) model
since it ignores any accelerations of the pelvis. Based
on this equilibrium concept, it should be apparent
that the magnitude of the HAM force is inversely
proportional to the length of the internal moment
arm, i.e., the smaller the internal moment arm, the
0893-7524/89/$3.50
Arthritis Care and Research Principles of Hip Joint Protection 147

u
HAM X D 1
INTERNAL MOMENT

I \ \
EXTERNAL MOMENT
I JRF
Figure 1. (A) Drawing showing the close-chained action of the hip abductor muscles (HAM).The HAM must generate an
internal moment for frontal plane stability of the pelvis and trunk about the right hip during single-limb support. For
stability, the internal moment must equal the external moment. (D = internal moment arm, D1 = external moment
arm, BW = body weight, JRF = joint reaction force. Note: A moment arm is equal to the length of a line that extends from
the axis of rotation to a point of right-angle intersection with a respective force.) Reprinted and modified from Physical
Therapy 65:306, 1985 with the permission of the American Physical Therapy Associaton. (B) A seesaw model may simplify
the biomechanical conditions of single-limb support (in Figure 1A) by making an analogy to two weights (forces) balancing
on a seesaw. Since BW is positioned twice the distance from the axis as HAM, balance (or equilibrium) will only occur if
HAM is twice the weight of BW.

larger the HAM force needed for equilibrium [Figure
1B.) Typical lengths of the external and internal mo-
ment arms have been reported to be approximately
3.4 and 1.7 in., respectively: a ratio of 2 to 1 [4, 51.
Therefore, this frontal plane model would require a
HAM force twice body weight to maintain static ro-
tary equilibrium. The key clinical point here is that a
relatively large muscle force is required because of
the relatively small internal moment arm that the
HAM operates [6]. (See Appendix 1,which uses hy-
pothetical data to estimate the forces required of the
HAM.) During many activities of daily living, the
large muscular HAM force is transmitted across the
hip joint, providing joint stability and aiding in the
nutrition dynamics of the joints articular cartilage
[7]. This muscle-produced joint force will be referred
to as the HAM rnyogenic joint force [3].
Myogenic joint forces play a significant role in de-
termining the hip joints total contact forces during
many weight-bearing daily activities [ 8 ] ,particularly
those that involve single-limb support. Besides these
myogenic forces, additional dynamic hip joint
forces exist because of the effect of the superimposed
body weight striking the ground [9] and, to a lesser
extent, forces produced by acceleration of body seg-
ments. Studies that include these factors have re-
ported a total hip joint force during average-speed
walking to range from 3.3 to 3.5 times body weight
[lo, 111. This force has been reported to increase
dramatically to about five times body weight during
running [ 121.
During single-limb support, the femoral head must
apply a joint reaction force to the acetabulum that
is at least equivalent to the sum of the myogenic and
body weight forces. Note in Figure 1A that the joint
reaction force has a line of action approximately par-
allel with the HAM force; however, it is oriented in
the opposite direction. Inman [2] has estimated the
148 Neumann
line of action of the joint reaction force to be about
10 to 15 from the vertical, which, by no coinci-
dence, is approximately parallel to the line of action
of the HAM force. (See Appendix 2 for a simple
method of approximating the hip joint reaction force
during standing on one limb.)
The production of large hip joint reaction forces
during walking is a natural consequence of bipedal
ambulation and the need for frontal plane stability.
A pliable acetabulum, in conjunction with a com-
pressible and lubricated articular cartilage, functions
to attenuate the effects of the peak joint reaction
forces so that pressures remain within the subchon-
dral bones physiological limit [13, 141. With hip os-
teoarthritis, the hyaline cartilage has lost its ability
to adequately protect the joint, resulting in a reactive
hyperactive response of the local bone.
HIP OSTEOARTHRITIS AND
HIP JOINTPROTECTION
Conservative treatment of hip osteoarthritis (HOA)
often involves educating the patient in methods to
decrease the forces that are transmitted across the
hip joint. This education assumes that hip joint reac-
tion forces exacerbate an acute condition and/or pre-
dispose further cartilage deterioration. Many hip
joint protection principles focus on decreasing the
magnitude of HAM myogenic force. As shown in
Appendix 2, about two-thirds of the joint reaction
forces at a hip in single-limb support can be attrib-
uted to HAM myogenicforces.
The therapeutic advantage of minimizing the
HAM myogenic force may be accomplished clini-
cally by a combination of (1)decreasing body weight
or external load, (2) decreasing the external moment
arm, and/or (3) increasing the HAMS internal mo-
ment arm [S]. These methods all are based on the
equilibrium equation depicted in Figure 1A. The
benefits of using a cane in the hand opposite to a
painful hip is also based on this equilibrium equa-
tion. Further explanation and clinical examples that
incorporate these hip joint protection principles are
illustrated.
Body Weight
Decreasing body weight will theoretically decrease
the frontal plane external moment produced about a
hip in single-limb support. This would subsequently
minimize the need for the HAM to generate an inter-
nal moment as well as decrease the force of body
weight. Because the 2 to 1ratio of the hips external-
to-internal moment arm lengths discussed earlier
(Figure lB), the assumption may follow that for
Vol. 2, No. 4, December 1989
every 1lb of body weight lost, the force requirements
of the HAM would decrease by 2 lb. In regard to
decreasing joint reaction forces, one may substitute
hypothetical data in the equations of Appendix 1
and 2 and observe that for every 1% of body weight
lost, the joint reaction forces of a hip in single-limb
support would decrease by an equivalent 1%. This is
only an approximation of the true biomechanical sit-
uation; however, it should serve as valid motivation
for the patient. This weight loss principle would spe-
cifically apply to persons whose body weight greatly
exceeds their ideal body weight. Larger body types
based on genetic predisposition may be equipped
with a proportionally larger internal moment arm
and/or thicker articular cartilage that may mitigate
the potential deleterious effect that large body
weight may have at the hip. Controversy exists
whether obesity is correlated with the development
of osteoarthritis at any joint [15-171. Therefore,
these suggestions on weight loss apply to persons
with HOA who are attempting to minimize hip joint
forces, not necessarily decreasing the likelihood of
acquiring the disease.
Trunk Deviation During Walking
Patients with unilateral HOA often lean their trunk
and pelvis toward the side of the painful hip during
single-limb support. This joint protection technique
is usually initiated by the patient and not necessarily
taught by the clinician. This frontal-plane gait devia-
tion is an antalgic response aimed at minimizing the
need for HAM contraction and subsequently mini-
mizing the myogenic joint forces through a painful
hip. The ipsilateral trunk and pelvis lean de-
creases the external moment about the hip in single-
limb support by decreasing the external moment arm
of the body weight force [18](Figure 2). In theory, if a
patients ipsilateral lean is dramatic enough, the
body weight force will fall through the hips center
of rotation, thus decreasing the stance hips (frontal
plane) external moment to zero. In this situation,
significant force production from the HAM would be
unnecessary, and the joint reaction force would de-
crease to approximately the patients body weight.
Patients with bilateral painful hips may incorporate
the ipsilateral lean during each hips stance phase,
i.e., twice within each gait cycle. This results in a
waddling gait pattern that is quite inefficient from
a metabolic standpoint [19]. As will be discussed,
the proper use of a cane will minimize the need for
the antalgic ipsilateral lean, as well as reduce hip
joint forces.
Patients with unilateral weakness of their HAM
often show an ipsilateral lean for fundamentally sim-
Arthritis Care and Research
\ arm-produced force toward the ground as the contra-
HAY X D
h )Yip)
\ duced moment and the right-HAM-produced mo-
, \
Figure 2. Frontal plane model depicting the decrease in
the external moment arm (DJ as a patient in (right) single-
limb support leans the trunk and pelvis toward the side of
hip osteoarthritis (compare D1 length with Figure 1A).
(HAM = hip abductor muscle, D = internal moment arm,
BW = body weight.) Reprinted and modified from Physi-
cal Therapy 65:306, 1985, with the permission of the
American Physical Therapy Association.
ilar reasons as that just discussed. They lean their
trunk and pelvis toward the side of the HAM weak-
ness to minimize the moment required of the weak-
ened HAM. Patients with a painful hip often develop
an associated HAM weakness secondary to disuse
atrophy. The lean incorporated by these patients
therefore serves the dual purpose of minimizing the
HAM myogenic joint force and the force demands
placed on the weakened HAM.
The magnitude of the ipsilateral lean may vary
with the severity of the pain (and/or HAM weak-
ness). The lean is usually more subtle and not as
exaggerated as that depicted in Figure 2.
Use of a Cane
A cane has been used as an assistive device to walk-
ing since ancient times [20]. Recommendations are
Principles of Hip Joint Protection 149
routinely made to patients with unilateral HOA to
use a cane in the hand opposite (i.e., contralateral) to
the affected hip [21, 221. The cane acts to transmit an
lateral (affected) hip is in the stance phase of gait. As
the frontal plane model in Figure 3 illustrates, the
ground returns the applied cane force back in an
upward direction, generating a counterclockwise
moment about the right (affected) hip. Note that the
cane-generated moment (CF x D2 in Figure 3) acts in
the same rotary direction as the moment naturally
produced by the right HAM. The counterclockwise
moment required for frontal plane stability about the
right hip may now be shared between the cane-pro-
ment. Less right HAM force would therefore be re-
quired, resulting in a diminution in the magnitude of
HAM myogenic joint force through the affected hip.
This theoretical unloading effect of the cane may
serve to protect a painful hip and/or prevent further
mechanical wear.
As Figure 3 shows, the moment produced by the
cane is the product of the cane-transmitted force
times the length of the canes moment arm. This
large moment arm allows a substantial moment to be
created by the investment of only a modest cane
force. Murrays research allows one to estimate that
an averaged-sized person with unilateral HOA
would generate a cane force of about 23 lb [20]. This
cane force, acting through a 14-in. moment arm, e.g.,
(Dz in Figure 3), would provide a HAM moment re-
duction of roughly 322 in.-lb. This is a significant
reduction considering that the HAM of an averaged-
sized person would need to produce an internal mo-
ment of about 510 in.-lb during single-limb support
[Appendix 1). Biomechaniral research by Brand and
Crowninshield [ 111 has estimated a 60% reduction
in hip joint reaction force in patients with HOA who
properly use a cane. It is theoretically possible that
the generation of a relatively substantial cane force
could completely substitute for the required contra-
lateral HAM force. In this case, the maximal joint
reaction force reduction would be limited to approx-
imately the persons body weight.
The overall biomechanic advantage of unloading a
hip through a contralateral cane force may be ex-
tended to conditions that do not involve a cane. For
example, standing and putting on trousers usually
requires a momentary unilateral stance over a pain-
ful hip. This activity may be performed with less hip
discomfort if a downward-directed force is simulta-
neously applied with the contralateral arm onto a
stable object, such as a dresser. Suggesting that pa-
tients sit instead of stand during lower extremity
dressing should eliminate most of the need for vigor-
ous HAM contraction.
150 Neumann
n
HAM x D
BW x D,
\ \ CF x Dz
As a general rule, patients with unilateral HOA
should avoid prolonged unilateral standing on a
painful hip. Minimal hip discomfort usually occurs
during bilateral standing, since the lower limb lo-
cated contralateral to the painful hip in effect serves
as a cane. Pilot work from our laboratory shows min-
imal, if any, HAM myoelectric activity during bilat-
eral standing. In theory, bilateral erect standing
results in joint reaction forces of only about one-
third of body weight at each hip [22].
Patients may report pain relief from using a cane
on the same side as their painful hip. In theory, how-
ever, using a cane in the right hand during stance
phase on a right (painful) hip would produce a cane-
generated moment in the opposite rotary direction as
that naturally produced by the right HAM (use Fig-
ure 3 to visualize this). This would require increased
right HAM force for frontal plane stability and subse-
quently increased myogenic right hip joint force.
The unloading effect that some patients express who
use the cane ipsilateral to their painful hip is proba-
bly due to the associated ipsilateral trunk and pelvic
lean that is characteristic of using a cane ipsilateral
to the affected hip.
Vol. 2, No. 4, December 1989
Figure 3. Frontal plane model showing how a cane
force (CF) applied by the (left) hand opposite to a
cF
(right) painful hip can decrease the amount of right-
hip abductor muscle (HAM) contraction. The bal-
ancing of the external moment produced by body
weight (BW x Dl) may now be the responsibility of
the right HAM and the cane force (D = internal mo-
ment arm, D1 = external moment arm, D2 = moment
arm of the cane force). Reprinted and modified from
Physical Therapy 65:306, 1985 with the permission
of the American Physical Therapy Association.
Load Carriage
Persons with HOA should be advised to carry exter-
nal loads that are as light as possible. If one must
carry a significant load, however, the manner by
which the load is carried will dramatically effect the
force demands placed on the HAM. A load carried
on the side contralateral to the side of HOA would
significantly increase the force demands placed on
the HAM of the side of the arthritis (i.e., right, as in
example Figure 4A). The contralateral load, acting
over a large moment arm (D2)produces a large exter-
nal moment that must be balanced by the right HAM.
Because of the small internal moment arm of the
HAM, a large muscular force must be generated and
transmitted through the joint. Data from earlier re-
search has shown that the HAM located on the side
opposite to a load (of 20% body-weight) produced
approximately twice the EMG than that produced
while walking without an external load [3]. This in-
crease in HAM myoelectric activity was apparently
due to the large internal moment that the HAM must
generate to offset the combined effect of body weight
and the contralateral-placed load. (The reader
should be cautioned that doubling the EMG does not
A. CONTRALATERALCARRY B. IPSILATERAL CARRY

IPS1 x DJ

IPS1

+ CL x D2

Figure 4. (A) Contralateral load carry: The force requirements of the hip abductor muscle (HAM) increases dramatically to stabilize
the combined moments produced by body weight (BW x D1)and the contralateral-placed load (CL x D,) (D = internal moment arm,
D, = external moment arm, D2 = external moment arm associated with the contralateral load). (B) Ipsilateral load carry: Carrying a
load ipsilateral to a hip (right, eg) would decrease the force requirements of the right hip abductor muscle (HAM). The moment
produced by the ipsilateral load (IPS1 X D3) acts in the same rotary direction as that required by the right HAM (HAM x D). (D3 =
moment arm associated with ipsilateral load. Reprinted and modified from Physical Therapy 65:310,1985 with the permission of
the American Physical Therapy Association.
152 Neumann
necessarily predict a doubling in the myogenic hip
force.) Patients should be advised not to carry loads
on the side opposite to a diseased and/or inflamed
hip. In contrast, loads should be carried on the same
side as the HOA for the following reasons.
If a patient must carry a unilateral load, the load
should be carried on the same side as the hip that
needs protecting. An upsilateral load carried by
the hand serves to decrease the HAM force required
during single-limb support. As Figure 4B illustrates,
the ipsilateral load creates a moment that acts in a
counterclockwise rotary direction about the right
hip. This ipsilateral load actually creates a moment
that acts in the the same rotary direction as the mo-
ment naturally produced by the right HAM. As with
the use of a cane, the load acts to share the obligatory
counterclockwise moment that the right HAM must
naturally produce, thus relieving this muscle of part
of its work demand. Research has shown that carry-
ing loads as large as 20% of body weight by the right
hand produced (statistically) no more right-HAM
EMG than that produced while walking without a
load [3]. Therefore, patients may protect a given hip
by carrying a load on the side of arthritis, which
fortunately leaves the contralateral hand free to use a
cane.
Health professionals should realize that the advan-
tage gained by carrying a load ipsilateral to a hip
with arthritis does not go without a price (as with
any modification of an activity of daily living). The
ipsilateral load, albeit shutting down the ipsi-
lateral HAM and affording some degree of joint pro-
tection, is a contralateral load experience for the chanter may be moved laterally in conjunction with
other hip during its stance phase. A possible alterna-
tive to the unilateral load carry may be to advise
patients to divide their load in half and carry each
load on separate sides of the body. Carrying loads
bilaterally, however, requires the use of both upper
extremities, which may interfere with cane use and/
or manipulating objects in the environment. If this
happens to be a major concern, loads may be carried
centrally on the upper back with a backpack. Re-
search has shown that carrying a single load (of 10%
body weight) on the back in a standard backpack
produced statistically no greater HAM EMG than
that produced during walking without a load [3].
This carrying method has the additional advantage
of not causing a contralateral load situation for either
hip side. Unfortunately, the benefit of the bilateral or
the posterior (backpack) load carriage is not fully
realized clinically, since these methods of load car-
riage are not very popular nor practical. Therefore,
the most useful advice is to suggest that unilateral
Vol. 2, No. 4, December 1989
loads be carried on the same side as the hip that
requires protecting.
HAM Internal Moment Arm
As Appendix 1 illustrated, the formula HAM X D =
BW x D1allows one to estimate that the HAM must
generate about 300 lb during single-limb support. If,
for the sake of discussion, the internal moment arm
were decreased by 0.5 in., the HAM force require-
ment needed for single-limb support would increase
to about 425 lb, or by about 40%. Severe cases of
HOA may lead to bone destruction and a decrease in
size of the femoral head and neck, thus shortening
the internal moment arm [23] (Figure 5B vs. 5A).
This loss in moment arm would theoretically result
in higher HAM and joint force during walking. Sig-
nificantly higher joint pressures may result, since the
increased joint forces would now be concentrated
over a smaller femoral head surface. This situation is
obviously not desired in a condition of severe HOA.
In theory, maintenance of a relatively large inter-
nal moment arm decreases the HAM force require-
ment and subsequently reduces the myogenic forces
through the hip [6). This may be accomplished by
certain orthopedic surgeries, such as a varus osteot-
omy or greater trochanter displacement. The normal
frontal plane angle between the femoral neck and
shaft measured medially varies greatly but on aver-
age is reported to be about 135 221. Decreasing this
angle increases the position of varus of the femoral
neck, which in turn increases the HAMs internal
moment arm [24] (Figure 5C vs. 5A). The greater tro-
a total hip arthroplasty. This surgical procedure also
serves to increase the mechanical advantage of the
HAM (i.e., increase the ratio of internal-to-external
moment arm), thus reducing myogenic joint forces
[23](Figure 5D vs. 5A). The rationale behind these
operations should be understood by the health pro-
fessional who works with patients with HOA.
Figure 5. Drawings showing a healthy right hip (A) with
hip abductor muscle (HAM) force and internal moment
arm (D). B-D show pathologic and surgical intervention
that alter the length of the HAMs internal moment arm.
(B) Hip with osteoarthritis and diminished HAM internal
moment arm secondary to partial disintegration of femoral
head. (C) Hip following a varus osteotomy with resultant
increase in the HAMs internal moment arm. Note that the
angle made by the dotted lines represents a varus angle of
about 90. (D) Hip shown following a surgical lateral dis-
placement of the greater trochanter that increases the
length of the HAMsinternal moment arm.
Arthritis Care and Research Principles of Hip Joint Protection 153

A B

C D
154 Neurnann Vol. 2, No. 4, December 1989

SUMMARY OF SELECTED HIP JOINT Equilibrium equation states that the sum of the
PROTECTION PRINCIPLES internal and external moments must equal zero:
C of the moments (torques] = 0
The following principles should aid the health pro- HAM force X D BW x D,
=
fessional in educating the patient with HOA in meth- HAM force = BW X D,/D
ods of protecting the hip. Other principles exist; HAM force = 150 lb x 3.4 i d 1 . 7 in.
however, this author chose to discuss principles that HAM force = 510 in.-lb/l.7 in.
specifically relate to the role of the HAM muscle in HAM force = 300 lb or twice body weight
the production of hip joint force.

I. Patients with HOA should be encouraged to de- APPENDIX 2

crease excessive body weight.
2. Patients with HOA tend to lean their trunk to the Figure 1A shows that the (nearly) upward-directed
side of the painful hip. Assuming relative length- joint reaction force (JRF)can be estimated by adding
length symmetry, this gait pattern should be con- the magnitudes of the down-directed forces of body
sidered a natural antalgic gait that minimizes the weight (BW) and hip abductor muscle (HAM) force.
need for hip abductor forces. First, use the equilibrium equation and solve for
3. A cane held on the side opposite to the painful the HAM force (as in Appendix 1).Second, assume
hip should be recommended to decrease that the sum of all upward and downward-directed
myogenic hip joint force and prevent an antalgic forces equal zero:
gait.
4. In general, patients with unilateral hip osteoar- C of vertical forces = 0
thritis should avoid single limb standing over [assign upward-directed forces positive and down-
their affected hip. ward-directed forces negative):
5. Loads that must be carried should be as light as
possible. JRF + -BW + -HAM force = 0
6. If unilateral loads must be carried, they should be JRF = BW + HAM force
carried on the side of the hip arthritis. This leaves JRF = 150 lb + 300 lb
the contralateral hand available for use of a cane. JRF = 450 lb
7. When possible, loads should be equally divided i.e., a force three times body weight acting superiorly
into two equivalent loads and carried bilaterally. through the hip joint. (Using an analogy to Figure l B ,
8. Factors that increase the internal moment arm of the upward-directed JRF exists between the seesaws
the hip abductor muscles will decrease the pivot point [i.e., femoral head] and the seesaw plank
myogenic forces at the hip. This is the basis of (i.e., the acetabulum] .)
certin orthopedic surgeries.

APPENDIX I
To estimate the force needed from the right HAM to
provide static single-limb support within the fron-
tal plane about the right hip, use the following theo-
retical anthropometric data and equation (refer back
to Figure 1A and text for abbreviations).
Data
Assume 150-lb person (excluding weight of right
lower leg) with internal and external moment arms
of 1.7 and 3.4 in., respectively. (Recall that a moment
is the product of a force times a moment arm.)
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The author thanks Ms. Joan Holcomb of Marquette Universitys The line of action of the HAM is about 15 from the vertical.
Instructional Media Center for her assistance with the illustra- Therefore to be precise, only 97Y0 (i.e., the cosine of 15) of the
tions. total HAM force is actually acting vertical.
Arthritis Care and Research
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