Yoga+Therapy+-+Fall+Prevention

=Yoga Therapy - Fall Prevention in Older Adults= =Molly Carr, Mary Crouch, Elizabeth Martin, Brooke Seever, Tyler Tabares= =Clinical Question:= What effect does Yoga have on fall prevention? =Evidence= =Background=
 * Balance
 * Fear of Falling
 * Gait Speed
 * Databases:
 * PubMed
 * Google Scholar
 * Search terms: “yoga therapy balance,” “yoga therapy balance older adults,” “yoga and balance,” “yoga and gait,” “yoga and older adults”
 * Inclusion criteria:
 * Available online at no cost
 * Recent within 15 years
 * Meta-Analysis, Systematic Review, Randomized Control Trial
 * Subject age 60+ living independently
 * Exclusion criteria
 * Case studies
 * Pilot studies
 * Unstable chronic disease (MS, cancer, PD, Alzheimer’s, stroke), severe neurological impairment
 * ⅓ of older adults (65+) fall each year
 * >> hospitalization, nursing home admission, and death
 * According to the CDC, the estimated cost of fall related injuries in 2020 will be $54.9 billion
 * ⅓ - ½ of older adults experience having trouble with balance and/or ambulation
 * 30% of older adults with no previous falls report having a fear of falling (FOF)
 * This FOF is double in those who have suffered a fall in the past
 * FOF can lead to depression, decreased QOL, decreased social activity, physical weakness, reduced participation in daily activities, increased risk of institutionalization
 * More common in women
 * According to the National Council on Aging, “falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults.”
 * 2.8 million+ falls/year treated in the ED
 * Equivalent to one fall-related ED treatment per 11 seconds
 * 800,000 hospitalizations/year
 * 27,000+ deaths/year

Generally Speaking...
 * Increased fall risk is correlated with
 * Reduced muscle strength
 * Reduced Power
 * low postural stability
 * Yoga increases
 * muscle strength
 * muscle endurance
 * muscle flexibility
 * balance and coordination
 * posture and core stability

Common tests and measures >> >> >>
 * Balance
 * Berg Balance Scale (BBS)
 * Mini Balance Evaluation Systems Tests (Mini-BESTest)
 * 1-leg stance
 * Functional Reach (FR)
 * Tinetti
 * Fear of Falling
 * Modified Falls Efficacy Scale (MFES)
 * Gait Speed and Mobility
 * Timed Up and Go (TUG)
 * Casual and Maximal walking speeds

Comparative Impacts of Tai Chi, Balance Training, and Specially-Designed Yoga program on Balance in Older Fallers (Meng, et. al. 2014) RCT used to compare the effect of a custom-designed yoga program with 2 other balance training programs.

Participants
 * 48 healthy older persons. Inclusion criteria: __>__ 60 years old, living independently, require no assistance with ADLs, and had fallen at least once in the past year.

Field tests
 * 8-foot up-and-go 1 <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;">, 1-leg stance, Forward Reach (FR), and casual and maximal walking speed
 * 1-leg stance & FR performed on both left & right sides
 * Each test performed twice

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;">Figure 1. Consolidated Standards of Reporting Trials flowchart. Abbreviation: SBEP, standard balance training program.

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Interventions <span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;">Each intervention had 2 sessions per week. Each group received a 5 minute warm up, 50 minute intervention, and a 5 minute cool down.

<span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; vertical-align: baseline;">__Targeted Yoga Program__


 * 13/16 participants assigned completed the intervention
 * Muscles that are significant contributors to balance were targeted by varying poses.
 * Including: plantar flexors, dorsiflexors, knee flexors and extensors, hip abductors and adductors, and core muscles.

<span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; vertical-align: baseline;">__Standard Balance Program__
 * 15/16 participants assigned completed the intervention
 * maintained balance on compliant surfaces; picking up objects from the ground; and line, cone, ladder, chair, step, and ball drills
 * 2-3 multicomponent drills were performed during each treatment session
 * Intensity and difficulty were increased by changing speeds of movement, reducing bases of support, and decreasing the stability of training surfaces



<span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; vertical-align: baseline;">__Tai Chi:__
 * 11/16 subjects assigned, performed the intervention
 * Whole-body motion using alternating fast and slow coordinated upper and lower body rotational movements.
 * 18 movements, including knee bends, small and large forward and backward steps, trunk rotation, and weight shifts, focusing on postural alignment and eye-hand coordination

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 8px; text-decoration: none; vertical-align: baseline;">https://img.washingtonpost.com/rf/image_1484w/2010-2019/WashingtonPost/2016/05/12/Health-Environment-Science/Images/iStock_000029437740_Large.jpg

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Results <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 24px; text-decoration: none; vertical-align: baseline;">Field tests- Performances significantly improved for all interventions (P<.005)
 * 8-foot up and-go speed improvements
 * Balance yoga 1.62 s*
 * Tai Chi .98 s
 * SBEP 4.8 s
 * 1-leg stance improvement:
 * Balance yoga L: 13.5 s, R: 10.4 s*
 * Tai Chi L: 9.8 s, R: 8.9 s
 * SBEP L: 4.8 s, R: 3 s
 * Functional Reach improvement
 * Balance yoga L: 4.9 cm, R: 4.1 cm
 * Tai Chi L: 3.4 cm, R: 6.12
 * SBEP L: 3.7 cm, R: 4.1 cm
 * Casual walking speed improvements
 * Balance yoga 0.81 s
 * Tai Chi 0.79 s
 * SEBP 1.22 s
 * Maximal walking speed improvements
 * Balance yoga 0.33 s
 * Tai Chi 0.44 s
 * SEBP 0.77 s

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 29.3333px; text-decoration: none; vertical-align: baseline;">The Effects of a Therapeutic Yoga Program on Postural Control, Mobility, and Gait Speed in Community-Dwelling Older Adults (Kelley, et. al. 2014)


 * 13 adults (12 women, 1 man) with little to no yoga experience
 * 60 years or older
 * Can maintain upright standing w/bare feet for 90 seconds independently
 * Intact LE sensation
 * 20/20 vision
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;">Mini-Mental State Exam (MMSE) score <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; vertical-align: baseline;">__>__ <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;"> 24
 * Quasi-experimental study examining the effects of 12-week therapeutic yoga program on
 * Gait speed
 * Postural control
 * Mobility

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Yoga Intervention
 * Participation eligibility was determined by
 * MMSE, monofilament testing, eye exam
 * Prospective participants were screened via a medical history questionnaire
 * Mini-BESTest was completed and gait speed was measured
 * Yoga teachers (3 authors) were blind to the results of the outcome measures
 * After 12 weeks, the participants were retested on
 * Mini-BESTest and gait speed
 * Sessions
 * 60 min. of Kripalu-style yoga
 * Included:
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;">Breathing exercises (pranayama) and body awareness - <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; vertical-align: baseline;">__5 minutes__
 * Diaphragmatic breathing
 * Full yogic breath
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;">Warm-up activities - <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; vertical-align: baseline;">__5 minutes__


 * Seated shoulder circles
 * Wrist and neck rolls, standing heel & toe raises
 * Hip circles
 * Heel walking
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;">Physical postures (asana) in seated, standing, supine - <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; vertical-align: baseline;">__40 minutes__
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; text-decoration: none; vertical-align: baseline;">Meditation and savasana - <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 16px; vertical-align: baseline;">__10 minutes__
 * Specifically designed for older adults with impaired mobility and postural control
 * Standing yoga postures
 * Mountain pose
 * Warrior I
 * Warrior II
 * Triangle pose
 * Tree pose
 * Goddess pose
 * Warrior III
 * Half-moon pose
 * These poses were chosen to increase strength in the
 * Quadriceps
 * Tibialis anterior
 * Gastrocnemius
 * Target potential gait and balance deficits
 * Other poses
 * Downward-facing dog
 * Bridge pose
 * Bound angle pose
 * Each session ended with relaxation in corpse pose

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Results
 * 35 began initial program
 * All participants were required to attend 19/24 sessions to be eligible for posttesting
 * 13 completed biweekly program
 * Of the 13 who completed
 * 9 attended 80-90% of classes
 * 3 attended 90-99% of classes
 * 1 attended 100% of classes


 * Yoga group
 * Paired t-tests reveal statistically significant improvements in gait speed and mobility
 * Self selected gait speed: p=0.015
 * Fast gait speed: p=0.001
 * TUG: p=0.045
 * TUG-DT (dual task): p=0.050
 * Statistically significant improvement in postural control and mobility
 * Mini-BESTest: p=0.039
 * Average improvement
 * in TUG score was 0.53 seconds
 * in TUG-DT score was 0.21 seconds
 * of normal gait speed was 0.89 m/sec
 * of fast gait speed was 0.22 m/sec

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Discussion
 * The results support the use of a 12 week yoga program to improve postural control, mobility, and ambulation
 * Many poses work to stabilize hip and core musculature
 * As well as other muscles of the LE that are fundamental for posture and ambulation
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; vertical-align: baseline;">__Mountain pose__ <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"> may
 * Improve pelvic stabilization and postural control due to coactivation of hip flexors and extensors
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; vertical-align: baseline;">__Warrior I__ <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"> emphasizes stepping and weight shifting
 * Improves quadriceps and hamstrings muscle length
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; vertical-align: baseline;">__Warrior II__ <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"> also emphasizes stepping
 * May stretch the adductors
 * Strengthen hamstrings and gluteus maximus
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; vertical-align: baseline;">__Tree pose__ <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 17.3333px; text-decoration: none; vertical-align: baseline;"> may improve gastrocnemius and hamstring muscle strength and unilateral stance
 * “The participants in this study showed a clinically meaningful improvement in fast walking ability, which could lead to improved balance and functional mobility and reduce energy expenditure and risk for disability and falls.”

Mountain pose Warrior 1 Warrior 2

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">The Effect of Yoga on Balance and Fear of Falling in Older Adults - (Nick et. al., 2016)
 * RCT to determine how yoga affects the balance and FOF in older adults
 * 40 participants (17M, 23F) age 60-74
 * BBS score <45 - indicates higher likelihood of falling
 * MFES score <8 - indicates FOF on a scale of 1-10
 * 20 received the intervention
 * Two 1-hour yoga classes per week for 8 weeks
 * 20 were in the control group
 * No yoga

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Intervention
 * Each Yoga Class was taught by a certified yoga instructor
 * 2 additional trained staff members were always present to minimize chance of falling during class
 * Class Structure - Hatha Style Yoga
 * 10 minutes of Pranayama (breathing exercises)
 * 10 minutes of stretching and orthopedic warming exercises
 * 30 minutes of Pavanamuktasana and balance movements
 * 10 minutes of Savasana (deep breathing while lying on back and closing eyes)
 * Participants were made aware of the muscles being contracted, stretched, and steadying the body while holding the various poses
 * Deep breathing was encouraged throughout each session

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Results and Discussion




 * Significant differences were found with both BBS and MFES scores between pre and post intervention for the yoga group
 * Yoga requires balance, strength, and flexibility
 * All factors that affect falls in older adults
 * All were emphasized in yoga intervention
 * The results show a positive influence of yoga on both balance and FOF in older adults

=Common Poses Used for Yoga Therapy= <span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Tree Pose <span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://s-media-cache-ak0.pinimg.comx/f/736e/0f/08/fe0f08a40910c634384d8f1b3200f6b3.jpg

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3814077/figure/fig13/

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Warrior I <span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">http://ffden-2.phys.uaf.edu/211_fall2013.web.dir/Molly_Tedesche/Virabhadrasana%20I_2.png

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3814077/figure/fig5/

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Warrior 2 Bio-mechanics of Warrior 2 Pose media type="youtube" key="6VLdJVHjRfQ" height="360" width="640"

Front Limb
<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://img.gtvcdn.com/cdn/farfuture/xE9A1MOh_iqHhKpOxx-UAhcIc2ZZutTPCGp6V__RQyQ/mtime%3A1475333536/sites/default/files/imagecache/keyart_820x461/article_main_image/522-virabhadrasana-ii-warrior-ii-pose.jpg

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3814077/figure/fig14/

Back Limb
<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://skybluetrades.net/blog/posts/2013/04/28/bandha-yoga/bandha-yoga.png

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 9.33333px; text-decoration: none; vertical-align: baseline;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3814077/figure/fig15/

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Clinical Relevance
 * <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 18.6667px; text-decoration: none; vertical-align: baseline;">Collectively, these three studies shows significant improvement in 10 different tests for balance and gait. <span style="background-color: transparent; color: #616161; font-family: 'Proxima Nova'; font-size: 11.2px; text-decoration: none; vertical-align: super;">1
 * We can resolve with confidence that including yoga exercises in a physical therapy protocol can be beneficial in preventing falls in older adults through increased balance and safer ambulation.


 * Why is this relevant?
 * Integrate yoga into therapy sessions for variety, patient motivation
 * Provides one more “tool” in our “tool belt”
 * Poses can be modified for beginning to advanced levels
 * Poses can be included in HEP and/or discharge plans and can be easily integrated into daily activities:
 * Tree pose while brushing teeth
 * Warrior poses during commercial breaks while watching television
 * Classes at Senior center or Community living facility with experienced instructors offer opportunities for continued exercise/motivation after discharge

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">Meet Tao Porchon-Lynch



<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 14.6667px; text-decoration: none; vertical-align: baseline;">Tao Porchon-Lynch is the world’s oldest yoga instructor. At 98 years old, she still teaches 6 yoga classes per week and performs regularly as a competitive ballroom dancer.

<span style="background-color: transparent; color: #202729; font-family: 'Proxima Nova'; font-size: 37.3333px; text-decoration: none; vertical-align: baseline;">References <span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">Kelley KK, Aaron D, Hynds K, Machado E, Wolff M. The Effects of a Therapeutic Yoga Program on Postural Control, Mobility, and Gait Speed in Community-Dwelling Older Adults. Journal of Alternative and Complementary Medicine. 2014;20(12):949-954. doi:10.1089/acm.2014.0156.

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">Meng N, Mooney K, Richards L, et al. Comparative Impacts of Tai Chi, Balance Training, and a Specially-Designed Yoga Program on Balance in Older Fallers. ScienceDirect. http://www.sciencedirect.com/science/article/pii/S0003999314003426. Published May 14, 2014. Accessed April 11, 2017. [|__http://ac.els-cdn.com/S0003999314003426/1-s2.0-S0003999314003426-main.pdf?__][|___tid=43ae10a4-1eca-11e7-b6e8-00000aab0f01&acdnat=1491924152_34f1d749b23d54b390539143476adbd1__] <span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">)

[|__http://hdcs.fullerton.edu/csa/Research/documents/RikliJones1999FunctionalFitnessNormativeScores_000.pdf__]

[|__http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1132__]

<span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">Nick, N., Petramfar, P., Ghodsbin, F., Keshavarzi, S., & Jahanbin, I. (2016). The Effect of Yoga on Balance and Fear of Falling in Older Adults. Pm&r,8(2), 145-151. doi:10.1016/j.pmrj.2015.06.442. [|__https://www.ncbi.nlm.nih.gov/pubmed/26164350__]

<span style="background-color: #ffffff; color: #303030; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">Oken, B. S., Zajdel, D., Kishiyama, S., Flegal, K., Dehen, C., Haas, M., … Leyva, J. (2006). RANDOMIZED, CONTROLLED, SIX-MONTH TRIAL OF YOGA IN HEALTHY SENIORS: EFFECTS ON COGNITION AND QUALITY OF LIFE. Alternative Therapies in Health and Medicine, 12(1), 40–47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1457100/

<span style="background-color: #ffffff; color: #303030; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">Salem, G. J., Yu, S. S.-Y., Wang, M.-Y., Samarawickrame, S., Hashish, R., Azen, S. P., & Greendale, G. A. (2013). Physical Demand Profiles of Hatha Yoga Postures Performed by Older Adults. Evidence-Based Complementary and Alternative Medicine: eCAM, 2013, 165763. [|__http://doi.org/10.1155/2013/165763__] <span style="background-color: #ffffff; color: #303030; font-family: Arial; font-size: 16px; text-decoration: none; vertical-align: baseline;">.

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