Sjogren's Advocate: Fatigue, pain and brain fog? Don't blame it on fibromyalgia

As usual, Dr. Sarah's most recent post on Sjogren's Advocate is excellent. Here is the first few paragraphs, but head over to read it all:

Sjogren's symptoms can look like fibromyalgia 

Many Sjogren’s patients are told they have fibromyalgia, without anyone ever considering the possibility of a Sjogren’s diagnosis. Sjogren’s symptoms can look a lot like fibromyalgia. Fibromyalgia is a diagnosis of exclusion. Once Sjogren’s is diagnosed, the “fibromyalgia” label should be dropped.  

Fibromyalgia is a syndrome, not a disease (181). It is cluster of symptoms that is not associated with objective markers. On the other hand, Sjogren’s is a well-characterized immune-mediated disease, not a syndrome. While Sjogren’s is not always easy to diagnose, there are numerous biomarkers (indicators) of the disease. The name “Sjogren’s syndrome” is inappropriate and outdated, and is slowly being replaced with “Sjogren’s disease” or simply, “Sjogren’s” (188). Continue reading here. 

Yep. Agree 100%.

I was initially diagnosed as having fibromyalgia, as I did indeed meet its criteria. I hurt. Everywhere. I was exhausted beyond belief, and my brain was mush, especially when my fatigue was at its highest. Eleven -- yes ELEVEN years ago, I expressed my numb brain this way: 

........So, I have had a week where the ol' grey matter just isn't functioning at it's peak. This used to freak me out considerably early on in my experience with autoimmune disease. You know the feeling - it's as if any thought process is in sloooooooow mooooooootion. Retrieval of items in my memory feels like rummaging around blindly for my size in a mile high stack of clearance sweaters at JC Penny. It's possible to find what you need. But it takes forever.

You can read the rest of my post here. Be sure to read the comments, which are amazing. 

Luckily, my doctor also ran blood tests for autoimmune diseases, which proved that all of the above was related to Sjogren's. She then removed fibromyalgia from my diagnosis list, so I was fortunate in that respect. 

Has your medical care been compromised due to an inaccurate fibro label? 

Hiya

 It's been too long since we talked, I know. Thank you to those that checked in with me to make sure that I was still breathing and all; indeed I am! Y'all are so kind.

Here's what I have been up to since my last post. 

This amazing device alerted me to my heart arrhthmia, which although is not serious, is still good to know. As a result of a cardiac workup, I now can put a name to those annoying irregular heart beats (premature atrial contractions in frequent bigeminy) and I have learned that I have inherited my dad's leaky mitral valve. Who knew? I certainly didn't until I ran an ECG strip via my iWatch. Amazing. 

It also can alert EMS if I take a nasty fall, can measure my pulse and blood oxygenation, but best of all -- I CAN CALL TERESE TO HARASS HER FROM THIS THING. 

I feel like Dick Tracy while wearing it. 

Yes, I will be good and follow up as recommended with my cardiologist and even more importantly: will follow his advice. Even if it means getting a valve repair or replacement at some future point.

We had a smaller version of our annual Easter Ham-O-Rama last weekend. What a hoot. We ate too much, had a one kiddo egg hunt, and flung Peeps to our hearts' content. 

Ahhhh. I love Easter.

I love my Easter rolling pin. It makes the best designs in shortbread cookie dough. And it is easy to use for people with tremors like me. 

This grandchild is getting big so fast! He's morphed into a kid. Overnight. 

I love the flowering plum trees that line our driveway.

Grandkiddo is moving far too fast for this creaky old gramma.

We even were graced with this amazing rainbow. 

I'm thinking that it reminds us that far better days are ahead. Especially since I have received both doses of the Covid-19 vaccine. 

I hope that y'all have been Reasonably Well. Hugs. 

Sjogren's Quarterly: Why Language Matters

 I enjoy all of the Sjogren's Syndrome Foundation's publications. The most recent edition of Sjogren's Quarterly, The Professionals' Resource on Sjogren's lead article was entitled "Why Language Matters" and written by Florian Kollert, MD and Benjamin A. Fisher, MD. It was a very interesting read in which the authors voiced their concerns over the use of 'primary' and 'secondary' terms to classify Sjogren's Syndrome. Here's an excerpt: 

Historically, Sjogren's has been classified into 'primary' and 'secondary' disease. 'Primary Sjogren's is defined as a standalone entity occurring in the absence of another systematic autoimmune disease, whereas 'secondary' disease is associated with the presence of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or systemic sclerosis (SSc), for example. Notably, the presence of a coexistent autoimmune disease is very common in Sjogren's (approximately 30% overall) when organ specific autoimmunity is also included.

In our recently published article (Kollert & Fisher, Rheumatology) we reviewed the historical justification for the distinction of 'primary' and 'secondary' Sjogren's based on genetics, clinical presentation, chronology, histology and serology, and found it difficult to justify the dichotomy based on existing evidence. We therefore recommend further research, and advocate abandoning the term 'secondary' unless strong evidence emerges of a pathological difference between these subsets. We further argue for a nomenclature including the associated disease (Sjogren's in association with...) to not only emphasize the second autoimmune disease but also Sjogren's itself. In our perspective, Sjogren's is an under-researched disorder, a situation that is even worse for patients with so called 'secondary' disease. This stands in sharp contrast to the potential impact of Sjogren's on quality of life, even when compared to other systemic  rheumatological disorders..............

.........Patients with 'secondary' Sjogren's are often excluded from clinical trials and were not incorporated in the development of the most recent classification criteria for Sjogren's. They were considered in the widely used 2002 criteria but neither histopathology nor autoantibodies were necessary for classification as 'secondary' Sjogren's. Thus, recent clinical trials investigating new compounds for patients with Sjogren's typically recruit patients with primary Sjogren's only. So it seems unclear if a drug which is eventually proven to have efficacy for these 'primary' Sjogren's patients; will be accessible to patients with 'secondary' disease also. Conversely, studies of other systemic autoimmune diseases such as lupus or rheumatoid arthritis have typically not excluded patients with concomitant Sjogren's. This provides a largely unexplored opportunity to derive additional early signals of potential efficacy in Sjogren's.......

.......Taken together, as there is currently no evidence for a major difference between the phenotype of 'secondary' and 'primary' Sjogren's we argue in favor of using the same set of classification criteria for both. Moreover, we take the side of abandoning the term 'secondary' in favor of 'Sjogren's in association with' to emphasize not only Sjogren's but also the associated autoimmune disease. The overlap between different systemic autoimmune diseases should be regarded as an opportunity to foster drug development and to further stratify our available treatment modalities and personalize our therapies. 

Well said. I agree on all points. 

Has your rheumatologist diagnosed you with 'secondary' Sjogren's syndrome? Has your care been affected as a result? 

As Promised

 Here is the photos from this year's Christmas shenanigans. It was a great week; quieter than other years but just as fun. Perhaps there is a message for me there? Hmm....

This week, as is always after a holiday, is being spent resting and recuperating. And, as always, I am left feeling as though the post holiday fatigue is worth every minute spent recovering. 

I hope your holidays were rewarding as well.

Happiest of Holidays!

 My laptop has gone slightly bonkers today, which is lousy timing since I wanted to write a lengthy post which had zillions of pictures.

But.

I can't import images today.

So I'll just wish you all happy holidays; Merry Christmas, and a Happy New Year. I hope your holidays are festive and heartwarming. 

I love you guys. 

See y'all when I get this computer thing resolved. 

Have some eggnog and fudge in the meantime!

It Could Have Ended Much Worse

 While I was hanging onto the screen door handle for dear life and dangling off the edge of the stair landing, once I was certain that I would escape significant injury, my next thought was, "Gee. Maybe I won't tell John about this...."

My dumb stupid lack of balance had struck again. 

Did I tell you about my latest flirtation with a fractured hip?

No?

Well. Anyone who knows me, also knows that since autoimmune disease made its appearance, my clumsiness has increased exponentially resulting in stitches, broken bones, scrapes and impressive bruises. Wasn't a pretty sight.

But since moving into our home that has a master on the main level, I have avoided catastrophic injury. Woot! Country living AND fewer emergency room visits!

The only issue as with respect to safety for klutzes was the lack of stair railings on the outdoor steps. We debated style and types of railings and whether we should completely reconfigure the entryways for two years. Since it was only two steps up, I figured we had plenty of time.

Until I was lugging three bags of groceries into the house and slipped sideways off the stoop. Which brings us to the dangling incident. 

Two days later, I came to my senses and realized that I should let John know; and by the weekend he had installed two dandy sturdy railings. 

I realized that it was not wise for me to try to hide the fact that my balance issues were still alive and well. Dumb stupid misplaced sense of pride. 

I used to be so embarrassed to use scooters in stores, but once I swallowed my pride and use them when I need them, I am perfectly content to zoom up and down the grocery store aisles without a care.

Well.......except for the time that I took a corner too sharply and took out an entire Foster Grant sunglasses display. Oops. Luckily the staff was super friendly and had things put to right quickly. 

Do you struggle with your pride keeping you from accepting or seeking help? 

Autoimmune Disease is Not For Wimps

 

Image found here. 

So here I am; covered in sweat and am a shaky, exhausted mess. 

It’s not pretty.

Silly Julia. I had the audacity to expect that if I chose to make a small three ingredient batch of cookies today having not done much of anything, I would be able to do it without depleting my energy stores to zero. 

Hoo boy. Was I wrong. So not only am I stinky and slimy and crabby beyond belief, I have dropped to zippo energy levels and am feeling the need to vent. To someone who would truly understand. And, of course, that means I need to share with y'all, my friends. 

I appreciate having this outlet so much. 

It has been a rocky year for me overall. Like everyone, I am sick to DEATH of the pandemic and social distancing. I really don't like campaign years, and this is no different. But this stinko year has added autoimmune insult to injury and has seemed like one giant flare ever since I started the New Year with a serious case of shingles. 

I won't bore y'all with all the nasty details. They're laid out in all their grossness in previous posts. 

Bottom line is that I have been clobbered with a plethora of strange symptoms, new diseases, and medication misadventures, which have taken a major toll on this old body; and when those events all combine in a short span of time, my biggest and most anxiety producing symptom is by far fatigue. 

I definitely have whined about my fatigue here before. So those who have read my older posts have gotten an eyeful. But this go-around seems to be setting my "normal" bar on energy lower and lower. I have told my rheumatologists since day one that exhaustion, fatigue, and non-restorative sleep are my most significant symptom of autoimmune disease. I know that a great deal of us in this community feel the same. Historically, although doctors heard from their patients that autoimmune fatigue could be life-changing, the typical reaction from health care providers could best be described is indifference. Unfortunately, many physicians who have not been adequately educated about this devastating symptom adopt the same technique of care. 

I'm hoping that with continued education, that attitude will change. I have been so fortunate to have had rheumatologists and internists that have been supportive and encouraging in my battle with the fatigue beast. At a recent appointment, Dr. Young Guy gently acknowledged to me that he feels that aside from minimizing my inflammation and promoting general good health strategies, he has run out suggestions for fatigue specific treatment. Bummer.

In the future, hopefully we will understand the mechanism behind this bone crushing symptom. Recent studies such as this one will help us along. This excerpt was taken from Frontiers in Immunology:

Published online 2019 Aug 6. doi: 10.3389/fimmu.2019.01827

PMCID: PMC6691096

PMID: 31447842

Fatigue, Sleep, and Autoimmune and Related Disorders

Mark R. Zielinski,1,2,* David M. Systrom,3,4 and Noel R. Rose5

.......................

Introduction

According to the National Institutes of Health, autoimmune diseases are estimated to afflict over 20 million individuals in the United States (1, 2). Currently, there are over 100 recognized autoimmune diseases (3), and the prevalence of many autoimmune diseases continues to rise (4, 5). A recent self-reported survey of individuals with autoimmune and related disorders by the American Autoimmune and Related Disorders Association indicated that this population's primary concern is fatigue (6). Over two-thirds of respondents reported that their fatigue was profound, debilitating, and prevented them from completing simple everyday tasks. Indeed, a growing literature indicates that fatigue is common in most autoimmune-related diseases, as well as among individuals with related immunodeficiency disorders (7–12). Furthermore, it is estimated that 7–45% of people in the general population exhibit persistent fatigue (13), while almost 98% of individuals with autoimmune disease report that they suffer from fatigue (6). Fatigue can cause dramatic impairments in mood (14), diminish social aspects of life (15), lead to an inability to perform routine daily activities (16), and limit physical activity and work (17). Consequently, fatigue can severely affect well-being and has a financial burden on the individual, family, and society (18–21).

Fatigue is multifaceted and typically broadly defined making it difficult to decipher the causes in specific autoimmune diseases (19). Fatigue is generally described as a condition with prolonged periods of exhaustion accompanied by the inability to perform activities to an expected capacity. There are numerous aspects of fatigue that can be assessed that define the type of fatigue including the severity of functional impairment; time-of-day/circadian patterns of fatigue; length of the persistence of the fatigue from seconds to days; time between fatigue periods; duration of time necessary for the fatigue to dissipate; influence of sleep loss or disturbances in sleep; impact of depression or anxiety; degree of distress concurrently occurring with the fatigue; type of impairment, such as is cognition, motivation, attention, or physical abilities; and the type of physical performance or activity that is impaired, such as in walking, climbing stairs, socialization, chores, cooking, bathing, work, and sex. The type of fatigue experienced in autoimmune disease is variable These differences are likely related to the particular tissues/organs, cell types, brain areas, and molecular and physiological mechanisms affected by the condition (19).

Currently, there is a lack of efficacious long-lasting treatments for individuals experiencing fatigue in autoimmune disease. This is due, in part, to the limitations in our understanding of the multiple mechanisms responsible for fatigue. Evidence suggests several physiological functions can contribute to fatigue including oxygen/nutrient supply (22, 23), metabolism (24), mood (14), motivation (25), and daytime sleepiness (26, 27). Interestingly, inflammation is altered by many of the factors that modulate fatigue and vice versa (25, 28–30). Growing evidence indicates that neuroinflammation is a primary factor contributing to fatigue (25, 31). Since inflammation plays a large part in inducing fatigue, it is plausible that inflammatory pathways and the subsequent physiological alterations modulated by the inflammation are treatable targets for fatigue in patients with autoimmune disease. Indeed, evidence in autoimmune and related conditions, such as neurosarcoidosis, which is associated with increased lung inflammation, sleep disturbances, and fatigue, exhibit reduced fatigue from anti-inflammatory treatment (32). Herein, we discuss the role of factors contributing to fatigue in autoimmune disease including inflammatory-related mechanisms, relationships between peripheral and central nervous system (CNS) inflammation, particular brain areas and neurotransmitters, and cerebral vasohemodynamics (Table 1).

.............

Figure 1

found here, in the journal Frontiers in Immunology

Continue reading here. 

Over the years, I have learned several lessons in battling my fatigue, the most important being this: to be relentlessly honest in my self assessment of energy levels. If I push myself beyond my capabilities when artificially propped up with prednisone or caffeine, I always -- but always -- crash and burn. And require several days to recuperate. Being the stubborn individual that I am, this is one with which I still struggle. Pacing is also vitally important, as is setting realistic goals. 

Sigh. While these guidelines seem logical, they are really hard to implement. It is especially hard for me this year since being sensible about managing my energy is almost impossible when I don't actually KNOW what my energy reserves are. My limits fluctuate wildly from day to day; sometimes even hour to hour. 

Ah, but the battle continues. I know from experience that another very important tenant in managing my fatigue is exercise. If I simply plop myself in a recliner and give up the fight, long term my reserves will plummet to absolutely nothing and my muscles weaken. So even on those days when I am most exhausted, I do some kind of exercise. I have invested in a recumbent exercise bike, which I absolutely love. Just a few minutes a day may be all I can manage on flare days, but I feel better after, without exception. Good nutrition especially avoiding refined sugars is important, as is maintaining a relatively healthy weight. 

How do you manage your autoimmune fatigue?  

And now for something completely different

 My posts lately have definitely been of the whiny-butt persuasion. I thought it would be mutually beneficial to us if I shared some of the positives in my life these days; the idea being that the crummy times would be balanced out with all of the good ones. And there have been several. 

The good may outweigh the not so good, come to think of it. I think this exercise is proving fruitful already. 

So. Ready for the slide show of positivity? You are?

Get the lights, would you, Terese? 

We'll start with the little person that makes me smile every time I see him. He's so jam packed with cuteness I almost can't stand myself. I'm grinning so hard my cheeks hurt. 

These green old beauties were my dad's. Ah, what memories. As soon as I was old enough to swing a hay bale hook, my brothers and sisters and I made hay while the summer sun was shining. I took my turn steering the tractor, the baler, and the hay wagon around the fields and I have to laugh remembering what a steep learning curve I had trying to master that task. I was far more skilled in lining up grain wagons to the feed elevator. It was hard work, but any farm kiddo in the tri-state area was doing the same. It was just what we did. What a lot of work -- but oh, did it feel good to jump in a nearby lake after the last bale was unloaded each day. 

My niece sent this picture to me this week, letting me know that she and her husband have polished up the old John Deere and have put her back to work. Is that not amazing? Dad would be tickled pink to see her making hay once again. I am too. 

Speaking of heavy equipment, I've developed new skills this summer as John prepares to have a new storage shed built. We are going to put it next to my greenhouse AKA storage shed. See all the gravel? 

See the woman manhandling the compactor over all that gravel? In a dress and leggings? I like to dress for special occasions...and for real comfort. Love those cotton t shirt dresses. I always go for the comfy wumfy look when working construction. 

I loved the mini front end loader! We rented this one but I want one of my very own! It is controlled by two joysticks so it felt like playing a video game in real life. I'm sure that I could put it to good use. 

In other good news, my flowers and garden are blooming and growing. Last year, these gladiolus didn't blossom and I threatened the bulbs with uprooting them and tossing them into the burn pit if they didn't produce at least two blossoms this summer. Aren't they pretty? It was a great surprise. 

Glads, well done. You get to stay in your garden bed. 

It appears that one of my favorite garden veggies has sprouted and grown and are actually producing something which will be edible soon. Love those cucumbers. Grow really fast, guys. 

Let's see...what else.....oh, righto. My hammock swing situation. I previously had thoroughly enjoyed not one but two of these wonderful devices here on Mount Norway. One suspended from a branch of the biggest maple tree on our property, and...

....one on our patio off the master bedroom. It's a splendid place to swing and enjoy morning coffee. Note: that is not coffee in my plastic wine glass. Any beverage can be substituted for coffee quite nicely and any time of the day.  

So I am beyond excited to share pictures of my newest hammock swing hanging underneath the deck. What a shady and wonderful location. Now I can swing and float to my hearts content almost anywhere. There's something so therapeutic about being suspended in a hammock: I feel almost as though I am swimming or floating. Me and my joints absolutely love the sensation. With the addition of this third hammock swing, I can count on being able to swing and float in the shade any time of day. I can follow the cool shade all around the house. Wonderful. 

John is getting quite skilled at installing these things, thank goodness. I wonder where else we could put one? There could never be too many hammocks around. 

Ahhhhhh.

So life is good when I take time to count my blessings. 

How are y'all? I'd love to hear about all of YOUR blessings. 

The Love it and Hate it Drug

Prednisone molecule image found on

Prednisone. 

Yeah. About four years ago, Dr. Young Guy and I made the decision to taper then discontinue the low dose daily prednisone that I had been taking for hmm......I don't remember exactly......but a lot of years. I had been taking it for the debilitating fatigue, malaise, and general joint pain that came with my flavor of Sjogren's. But as time passed, I think I became acclimated to it until I reached a point where I just didn't think it was as effective as it had been previously. Since steroids -- of which prednisone is one -- are extremely effective in inflammatory situations, but also come with some potentially severe side effects, I decided to stop taking it. And, for quite awhile, I was pleased with the results. One less side effect to worry about, one less pill on the morning stack. Not terribly noticeable that it was absent. Cool.  

To refresh your knowledge of prednisone, read this.                                        

So I haven't been on daily steroids for a long time. 

Until.

One morning last week, I woke up yet again to pain in my hands and feet; I had to grit my teeth to close my hands into fists, and I dreaded that first step out of bed. I lay there, opening and closing my hands and wondered why the heck I was starting my day that way. But I shuffled off -- slowly -- in my orthopedic bedroom slippers which were extraordinarily expensive and didn't help my pain at all -- and poured myself my first glass of cold brew coffee. 

Which is AMAZING. I make it myself having refined my process. I'll share that another time with y'all.

As the caffeine hit my brain cells clearing the first layer of brain fog, suddenly it occurred to me: THIS IS NOT MY NORMAL.

Duh.

I have been putzing around with these symptoms for at least three months. They began gradually and I think that, like the frog in the boiling water analogy, I became accustomed to the new pain and in some wackadoodle manner accepted it as routine. 

The frog analogy? If you haven't heard it, it goes something like this: If you put a froggie (poor little thing. I'm glad this is just a story. DON'T TRY THIS AT HOME, KIDS.) into a pot of cold water, then put froggie and pot over a very low flame, the water heats so gradually that he stays in the pot far longer than he would if he had been dropped into a pot of hot water. 

Sad, but true.

So like the froggie, I sat in my pot of water while these weirdo pains kept heating up. Finally last week, I made the decision to jump. And I'm so glad I did.

As anyone with Sjogren's knows, the symptoms of this disease are varied and insidious. I had been dealing with osteoarthritic pain in my hands for decades, but this was completely different, especially the fact that it was something that I awakened to every morning. I've been buying every kind of orthopedic shoes and insoles with metatarsal bars that I can find, which do seem to help during the day but the next morning, I am back to pain square one. My shoe rack is becoming embarrassingly full of pairs that seemed to be promising but didn't meet my expectations. Bummer. Expensive. 

I contacted Dr. Young Guy that day. He thinks that I have acquired some kind of inflammatory arthritis and prescribed a course of prednisone for me with a follow up appointment after I have been taking it for ten days. 

Which brings me back to the title of this post. 

After four days, I can say that my symptoms are less; still there but severity diminished. Whew. And, to add to the whole bizarre mix of symptoms, a mysterious itchy and scaly rash on my face that appeared over the last month is disappearing amazingly fast. 

So while I can definitely see some benefits to taking this round of prednisone, there is also some drawbacks, the most irritating being an irresistible urge to bury my face in a chocolate cake topped with ganache; warmed then served with a slightly melty scoop of vanilla bean ice cream.

Ooooo. Excuse me a sec as I refocus my eyes and return to reality. Whew. 

Some folks experience an appetite decrease while taking steroids, I however, am not as lucky and have carb cravings that stop just barely short of being totally overwhelming. So far I'm beating them back with lots of fresh fruit, wish me luck with that. 

Then there's this totally fake sense of energy. Dangerous stuff, that. I find myself beginning big tasks, then somewhere around 4 pm, *poof*. It all goes away leaving me feeling as though I have been dropped from a three story building. After which I need to get horizontal and stay that way until bedtime. I'm trying hard to rein in this sensation, with some success. So far. 

Luckily, my mood seems to lift somewhat when I am on pred. I am not certain whether this is due to decreased yukky symptoms, or is a result of artificial energy. But for whatever reason, I'm glad it is there. 

Because. 

I need some optimism right now even if it comes in the form of a little white tablet. I really, really, REALLY don't want to add yet another autoimmune condition to my already lengthy list. 

Aaaaaaaarrrrrrrgggggggghhhhhh. 

But I look forward to my next appointment with my rheumatologist when we can sit together, face mask to face mask, and discuss this thoroughly. 

I'll keep you posted. 

Brenda Doesn't Charge Nearly Enough

So, like most of us, during this weirdo pandemic, I have had to adapt to many things, like planning ahead and ordering groceries. And not spontaneously driving off in Sadie with Lulu bopping around in back seat looking for adventures which involve drive through windows and french fries.

And dealing with the fact that Lulu's awesome groomer, Brenda, is still not open for customers. Poor Lulu has been seriously shaggy, to the point that sometimes it is hard to see her little eyes through her overgrown eyebrows.

What an overgrown furry little canine. 

As a result, I have, with great reluctance, started to groom her myself. My goodness. This is very very hard work for both Lulu and myself.

Poor doggie.

I purchased an inexpensive grooming set online awhile back, and now have completed two sessions over the past several months, with, um.............interesting results.

Poor doggie.

The first attempt was a couple months ago, and took three days. It is HARD getting a trimmer through thick curly schnauzer fur. And then the ears? Are you kidding me? Our vet insists that all of the hair inside her little ears is removed to avoid recurrent ear infections. Then all that silky, tangled fur that grows from between and under her paws. Which tracks in mountains of dirt and mud and grass clippings. I still haven't worked up the courage to trim her nails that are colored black, which means it is impossible to tell where the nail ends and the quick starts. I would feel terrible if I cut it too far and she started to bleed. Owie.

And lets not even discuss trimming this dog's.....er....... nether regions. You know what I mean.

Poor, poor doggie.

Bless her little canine heart, Lulu has been remarkably patient with John and I as we struggle to minimize her overgrowth. I couldn't bring myself to take a picture of our scraggly first attempt, and was relieved when she eventually regrew most of her very unevenly cut coat. But the second time has gone somewhat better. It is still abundantly clear that a very amateur groomer has been manning the clippers and shears, but at least Lulu can be identified as a schnauzer. If one doesn't look too closely.

Oh my goodness. Those long little black nails.....

Just look at her woeful expression.Those poor little ears! 

When Brenda reopens her business, I am going to pay her far more than what she has been charging. She earns every penny.