Just watching golf on television is enough to see how much stress and strain is put on the low back with each swing. But give it a try sometime and you will experience firsthand why low back pain is so common among golfers -- whether in the amateur or professional golfer.In this article, Physical Therapist, Christopher Finn, from the Par4Success Golf Performance Center in Durham (North Carolina) presents current evidence from published studies and ideas from his own practice on injury prevention...
Studying the causes and ways to avoid adjacent segment disease (ASD) of the cervical (neck) and lumbar (low back) spine has become a major focus of research these days. But with the ever changing surgical tools and techniques, it is difficult to compare studies from 10 years ago with current studies. And that dilemma will continue into the future as treatment strategies change with evolving technology.Even so, efforts are being made to study the problem of adjacent segment disease (ASD) and ways...
Canadian Study Reveals True Measure of Problems After Spine Surgery
No one doubts that complex spinal surgeries come with a whole host of potential complications and post-operative problems. But the true measure of how often this happens and how serious the problems may be haven't been really reported until now. Most of the data published comes from hospital-based administrative databases.In this Canadian study from a large university hospital, we get an idea just what kinds of morbidity (probl...
Importance of Lumbosacral Kyphosis for Teens with Spondylolisthesis
The lives of children and teens with a condition known as spondylolisthesis can be negatively affected by the consequences of this problem. According to this study from Canada, spondylolisthesis in teens lowers their physical quality of life. They have back pain, tight hamstrings, and neurologic symptoms. The greater the angle of the lumbar vertebra on the sacrum, the higher the grade of spondylolisthesis and the lower the phys...
It is no secret that low back pain (LBP) is one of the most common ailments in adults and one they often seek medical help for. This fact seems to be a true constant around the world in developed countries. Now, a new study from the United Kingdom (England and Scotland) uncovers some additional information that may be more challenging than helpful.In a study of over 15,000 adults 25 years old and older, they found a 28.5 per cent one-month prevalence rate. Translated, this means that in a 30-day...
The mystery of low back pain and how to treat it continues. Pain, loss of function, and chronic disability can become the end result of an episode of acute nonspecific low back pain. Nonspecific means there's no fracture, infection, or tumor. Some aspect of joint, soft tissue, and/or biomechanics (the way things move) is amiss.Until scientists can pinpoint the exact cause of nonspecific low back pain, treatment is usually symptomatic: decrease pain as quickly as possible and restore normal movem...
In this article, Richard Deyo, MD presents us with new information about worker compensation patients who have chronic back and/or leg pain following spinal surgery. This condition is often called failed back surgery syndrome (FBSS). Most people return to normal function and work quickly after back surgery. But in the case of FBSS, pain continues even with conservative care (pain relieving medications, physical therapy).Failed back surgery syndrome (FBSS), is also known as post-laminectomy syndr...
How do physicians decide what treatment recommendations to make for patients with acute (early onset) of low back pain? Is it based on whether that patient is a man or woman (suggesting a sex-biased health plan of care)? Does the patient's socioeconomic status (SES) such as lifestyle, occupation, and education make a difference? And how much does the clinical presentation affect the decision-making process (especially if that presentation is from an emotional female)?These are the questions put ...
Here's a dilemma neurosurgeons and orthopedic surgeons face when it comes to advising patients with chronic low back and leg pain from disc disease. Epidural injections are a common way to treat this painful problem. For more information on the treatment of chronic low back pain with epidural (steroid) injections, see A Patient's Guide to Epidural Steroid Injection.Evidence is lacking in how well these injections work. The best way deliver the injections is also debated. With anywhere from 18 to...
Research has shown that patients with low back pain who develop fear-avoidance behaviors (FABs) are at risk for a poor outcome and greater disability. Studies have also shown that when FABs are addressed in treatment, patients have much better results. Despite this knowledge, routine care of low back pain does not include strategies to prevent or stop FABs.Fear-avoidance behaviors (FABs) refer to ways patients change their behavior, actions, movements, and activities based on the fear that their...
In a never ending effort to find ways to help patients with low back pain, many different treatment approaches have been tried. In this report, researchers from Spain take a look at the effectiveness of shock wave therapy (also known as vibrotherapy) and ultrasound in the treatment of both acute and chronic back pain.Both of these tools provide mechanical vibration to the spine in an effort to increase blood circulation, improve soft tissue stretch, reduce pain and stiffness, and speed up healin...
In this review article, neurosurgeons from Thomas Jefferson University Hospital in Philadelphia take a look at the diagnosis, treatment, and results of treatment for spinal cord injuries. They focus specifically on fractures and cord injury at the thoracolumbar area.The thoracic spine ends at T12 (the last thoracic vertebra). The lumbar spine (L1) begins right after T12. The union between T12 and L1 is call the thoracolumbar junction. Spinal cord injuries at this level can result in one of two n...
Bone morphogenetic protein known as BMP-2 or BMP for short is a growth factor (protein) that helps bone heal and promotes bone fusion. BMP reportedly helps speed up the recovery rate after spinal fusion. BMP is designed to promote bone formation by setting up an inflammatory reaction. This type of enhancer was developed to avoid problems that occur with traditional bone grafting.In this study, complications from the use of BMP with spinal fusion are explored. The neurosurgeons who conducted the ...
Low back pain from degenerative spondylolisthesis is often treated with spinal fusion when conservative (nonoperative) care fails to improve symptoms or function. But spinal fusion often results in the need for a second (revision) surgery. One common problem that develops is adjacent segment disease (ASD). The question this study attempted to answer is whether or not extending an L5-S1 fusion to include the sacrum can reduce the risk of adjacent segment disease.Before we go any further exploring...
Men involved in heavy manual labor worry they may end up with a herniated disc. How likely is this occurrence? Who is at risk and why? These are the questions asked by a group of researchers carrying out the Copenhagen Male Study and reported on in this article.The Copenhagen Male Study was started over 30 years ago. Over 5,000 men participated in the study. They started by completing a survey with questions about the presence of back pain. Many other individual characteristics were also collect...
The lines and wrinkles on our faces aren't the only signs of the inevitable aging process. Progressive degenerative changes have also been documented in the spine. One of the areas of great interest is the intervertebral disc. New biologic therapies for aging discs are the subject of this review article on the topic.There are 33 vertebrae or spinal bones. Between each vertebra is a disc made of tough cartilage with a fluid center. These discs provide the cushion that allows your backbone to bend...
Have you ever noticed how some people give in to their back pain while others push through and do whatever they want regardless of the pain? What makes the difference in these two groups of patients? What makes the persistent group keep on keepin' on? Why does the avoidance group give up?One way to better understand the difference in behavior among chronic low back pain sufferers is to look at self-discrepancies. These are the differences between how the patient sees him or herself versus how he...
The results of this study show that major league baseball pitchers can recover from a neck or back disk herniation. It may take a while but they can even return-to-play after surgical treatment. How did they come to this conclusion? Public records were searched for information from 1984 to 2009. They found 40 major league baseball pitchers with a history of disk herniation and then followed the results of treatment.Everyone included in the study had surgery for the problem. They either had a spi...
For this article, surgeons and physical therapists join together to present a current view on the diagnosis and management of sacroiliac joint (SIJ) pain. Anatomy (including nerve innervation) and biomechanics of the sacroiliac joint are reviewed. Drawings of the bones that make up the joint are provided along with photographs of test procedures and X-rays following surgical fusion.Fusion of the joint is really a last resort effort and only used when all other approaches have failed. Surgery to ...
Any time surgery is done on the spine, there is a risk of neurologic problems. Best case scenario is a mild loss of motor or sensory function that only lasts a short time. The patient has a full recovery back to normal. In a worst case scenario, the patient is paralyzed and stays that way. Understandably, surgeons do everything they can to avoid neurologic complications, especially serious ones that lead to loss of function and disability.When presented with the possibilities of complications as...
Adolescent idiopathic scoliosis (AIS) isn't an easy problem to treat. Just ask any orthopedic surgeon involved in the treatment of children with this condition. The cause of this type of spinal curvature in teens is poorly understood. That's why it's called idiopathic (unknown).There are many spinal curve types: fixed curves, flexible curves, structural curves, major curves, minor curves, thoracic curves, thoracolumbar curves, double curves, triple curves, and so on. Finding a way to accurately ...
Prevention, Recognition, and Management of Spine Surgery Complications
Despite the lengthy title of this news article, it doesn't really begin to tell you about all the information contained within! First, the specific spine surgery in question is anterior lumbar (from the front of the low back).This type of surgery is done for spinal instability that requires fusion, tumors that have to be removed, and infection that must be cleaned out. Not to mention disk degeneration, trauma, spinal deformi...
Cats may be able to land on their feet when dropped from the second story of a building but humans are usually not so lucky. The force of the impact up through the spinal cord can kill a person. If the legs are bent and the person hits first on the sacrum -- well that's another story.In this report, two cases of such injuries with sacral fractures are reported. The sacrum is a wedge- or pie-shaped bone that sits between the two pelvic bones. Above the sacrum is the lumbar spine.The last lumbar v...
When it comes to lumbar spinal fusion, surgeons have more than one choice in how they do this procedure. Interbody fusion has become a commonly used technique that continues to change and improve over time. In this study, results from surgeons' own experience as well as studies available are summarized for extreme lateral interbody fusion (XLIF). It might help if we explain a few terms before bringing you up-to-date on the study outcomes.An interbody fusion refers to the removal of degenerative ...
If you were 80 years old (or older) and had chronic low back pain, would you consider a spinal fusion? What if you knew you would live another 10 years, 15 years, or even longer? More octogenarians (80 years old and older) are making that decision. And with the new minimally invasive surgeries, the option of a simple spinal fusion to stop the pain may be available for more seniors than ever before.The first question that comes up when thinking about spinal fusion surgery in this age group is: sa...
Bracing continues to be used for children and teens with adolescent idiopathic scoliosis (AIS) but does it work? What's the evidence for brace treatment and who should it be used with? In this review article, Dr. Paul D. Sponseller from Johns Hopkins University Department of Orthopaedic Surgery brings us up-to-date on the practice of bracing for AIS.Dr. Sponseller presents both the results of various studies published in the past 25 years on this topic as well as current opinions on the use of b...
Patients are clamoring for less invasive surgical procedures. But before surgeons leap from open incision spinal fusions to the minimally invasive technique, it might be helpful to compare the results from these two approaches.If the minimally invasive procedure yields better outcomes, then great -- surgeons will want to get trained and pursue that method. But if there's no difference between the two, then some experts suggest maybe it's time to slow down and think about the direction spinal fus...
For almost 30 years surgeons have been fusing the lumbar spine using the popular transforaminal lumbar interbody fusion (TLIF) technique. The surgeon approaches the spine from the side rather than from the front (anterior approach) or the back (posterior approach).The TLIF method of lumbar fusion has many advantages. The lateral approach gives the surgeon access to the disc and disc space without applying excess pull or traction on the nearby spinal nerve(s). With a lateral approach, it is only ...
How can patients with pain in the low back pain, leg, sacrum, pelvis, or buttocks coming from the sacroiliac joint (SIJ) get relief? For the last 10 years, radiofrequency denervation (using radio waves to destroy nerve tissue) has been used as an alternative treatment. It's time to evaluate the results and see if this new approach is working and who might benefit from it the most.The sacroiliac joint (SIJ) is a complex joint with ligaments to support and stabilize it (hold it in its proper place...
Have you ever heard someone say they have to lose 50 or 100 pounds before the surgeon will perform a particular operation? But if you have ever watched the popular TV show Biggest Loser, then you know how much work it can be to shed those pounds.Obesity isn't just a lifestyle choice (though that is a big part). Fat storage and metabolism (breakdown) are highly complex body functions. Fat itself has recently been identified as an active endocrine (hormonal) substance. Survival mechanisms in the b...
For a very long time, spinal fusion was the answer to chronic low back pain. But with time, surgeons were also able to see that once the spine was fused, load transferred to the next segment caused degeneration there as well. They call this phenomenon: adjacent segment degeneration (ASD). Many solutions to the problem of ASD have been proposed.The use of artificial disc replacement has been one way to approach the problem. The hope is to preserve spinal motion while protecting the adjacent verte...
The role of Schmorl's nodes in disc degeneration is the topic of this study from Southern China. To understand Schmorl's nodes, picture two vertebral (spinal) bones with a disc between them. Now imagine a circular layer of cartilage between the disc and each vertebra. That bit of cartilage is called the end plate. Schmorl's nodes occur when the disc pushes through the endplate and into the next vertebra. On imaging studies these look like small hollowed areas. Schmorl's nodes can be seen on X-ra...
Ever wonder if that time you hurt your back will come back to haunt you? Disc degeneration is a common problem as we get older. Adding a back injury or trauma to the mix could speed up that degenerative process.To find out if this might be so, researchers studied 37 pairs of twins (all men) who were part of an ongoing Twin Spine Study in Finland. They interviewed the men about past back problems and history of injuries on every job they had ever had. The same questions were asked regarding back ...
Scientists from The Netherlands have found three new factors that might help predict which patients with low back pain (LBP) will go on to develop chronic LBP. They describe chronic LBP as pain that lasts six months or more.When it comes to low back pain, many researchers have attempted to find ways to predict who will get better and who won't. It's an important topic because so many people are affected by low back pain. The cost of treatment, lost wages, and lost productivity is in the billions...
There's nothing simple about any part of the human body. Even what appears to be a single layer of covering around the spinal cord and brain (the dura) has three layers. Thanks to the invention of the electron microscope, it is possible to magnify tissues enough to see the finest detail.Spinal surgeons and patients having spinal surgery are affected most by this discovery. Any time surgery is done on the spine, there is a risk that the dura will get torn or damaged. And if all three layers are t...
The problem of low back pain continues to be the topic of many research efforts. Studies so far have shown that psychosocial factors (e.g., work status, mental health, level of education, blaming work for pain) are linked with pain, disability, and failure to return-to-work.But are there other, more clinical risk factors for ongoing (chronic) low back pain and/or disability? This large study from Denmark suggests there are indeed other factors to consider. Some of the predictive risk factors sti...
Acute lumbar disc prolapse can be very painful. Back pain that goes down the leg (called sciatica) often brings the patient in to the physician's office for help. Pain is managed with Physical Therapy and medications such as antiinflammatories.Another form of drug therapy is with muscle relaxers/relaxants. The most common drug family of muscle relaxants used are the benzodiazepines (e.g., Librium, Valium). These drugs are also used to treat anxiety because they have a sedative effect. But concer...
The sacroiliac joint (SIJ) formed by the sacrum wedged between the spine and the hip is the subject of ongoing controversy and debate. Some experts refuse to believe the sacroiliac joint is a true synovial joint that moves. They base this opinion on the fact that there is very little sacroiliac motion that can be detected or directly measured.But most agree that not only does the sacroiliac joint move, it can generate pain that is felt in the low back or buttock area. Studies to that effect repo...
Disc degeneration and herniation are common problems leading to surgery to remove part or all of the protruding disc. But back and leg pain from disc problems can come back after surgery. The question is: where's the pain coming from? Is it the same disc, scar tissue formed after the disc removal, a new disc herniation, or something else?Recurrent lumbar disc herniation occurs in anywhere from five to 15 per cent of patients. So patients with back and leg pain that goes away after disc removal (...
Here's a surprising finding. In the first study of its kind, researchers from five hospital-based spine clinics discovered that most disc herniations don't come from lifting (heavy or light) objects. In fact, the majority (62 per cent) have no known cause. The patients say the back and leg pain (sciatica) just came on without warning.
Can you wait too long to have spinal fusion surgery? Some research has shown that waiting too long may mean a poor result -- the patient doesn't get the pain relief hoped for. But how long is too long? That's the focus of this study from Great Britain.Most people recover from back pain with a little time and attention. Those who don't are often treated with medications such as pain relievers or antiinflammatories. Some seek the help of a chiropractor, Physical Therapist, acupuncturist, or massag...
My father was diagnosed with spondylolisthesis which is causing pain in his lower back. What causes this condition?
Is there any treatment for when one vertebrae slips over another? My mother has this in her lower back and it's causing her quite a bit of back pain.
Are you an adult suffering with chronic low back pain? This article reviews the outcome so far of a study named "SPORT" which stands for: 'Spinal Patient Outcomes Research Trial'. The outcome of conservative vs: surgical treatment of patients with spinal stenosis, with and without accompanying spondylolisthesis is expained. Please contact your Physical Therapist at "client_company* in Congress Park, Denver Downtown, and Stapleton Area for assessment and advice regarding treatment of your low bac...
Physical Therapy in Congress Park, Denver Downtown, and Stapleton Area for Lower Back
Do you suffer with low back pain? This article talks about the variety of non-medication treatments available for people with back pain. Contact Atlas Physical Therapy for an assessment and specific treatment plan for your low back pain.
Does your young athlete have leg pain that has been related to his or her back? This article defines and discusses spondylolysis radiculopathy as the potential cause of this pain.
What's one exercise that can reduce pain, improve balance and coordination, while supporting your body weight and giving you a warm, fuzzy feeling all over? How does aquatic therapy in a pool of 90-degree water sound?Water-based exercise has many potential advantages over land-based exercise programs. The warmth and buoyancy combined with elimination of gravity eases joint pain and improves range-of-motion. And because the water gives resistance to movement, you can vary how much or how little r...
What's the difference between back pain that remains in the back, compared to back pain that also causes pain into your buttocks or leg? This article discusses the differences in types of back pain. Your Physical Therapist at Atlas Physical Therapy can assist you in differentiating your pain and then treating it appropriately.Low back pain with or without leg pain comes in many flavors. There could be just back pain or back pain that radiates (spreads) into the buttock region. Back pain accompan...
If you are curious about the proposed theories behind the use of acupuncture, this article gives an explanation of some theories behind the practice and reviews the current scientific evidence. The study results using acupuncture in the treatment of low back pain are varied and therefore inconclusive. Talk to your Physical Therapist at Atlas Physical Therapy to discuss the role of acupuncture in treating your back pain.Lower back pain, usually affecting both men and women between the ages of 30 ...
For many years, X-rays have been used to diagnose and measure scoliosis (curvature of the spine). No matter how young or old the patient is or where the curve is located, this technique has continued to be simple and reliable. In this study, researchers from the Scoliosis Research Institute in Korea take another look at the Cobb angle measurement. They compare two different starting and ending points used in measuring the angle of the curve.The Cobb angle is defined as the angle formed between a...
In the late 1990s, the United States government made it easier for doctors to order opioids (narcotics) to help relieve pain not caused by cancer, called chronic non-cancer pain. As a result, the prescriptions of opioids has grown so doctors could help treat patients living with chronic pain. Some studies showed that these medications could help treat chronic pain, however some of it wasn't very strong.Now, over 10 years later, it still isn't really known who well opioids relieve non-cancer pain...
While only one out of 2,000 patients are diagnosed with cauda equina syndrome, it is diagnosed in one percent to 16 percent of patients who have lower back (lumbar) disk herniations (bulging or slipped disks) and in two percent to three percent of patients who end up needed surgery for the herniated disks.Cauda equina syndrome, if left undiagnosed, may cause a lot of damage. It can cause loss of bladder or bowel control, and it can affect sexual function. Unfortunately, because the syndrome isn'...
Is low back pain (LBP) during pregnancy normal? If studies are right and half of all women have low back pain sometime during pregnancy, does that support the idea that this symptom is to be expected during pregnancy? Available studies provide only a snapshot of what's going on with women, pregnancy, and low back pain. The answers to these and other questions are not to be found in the many small studies already published. That's why the results of this very large study conducted in Iran involvi...
So, you or someone you know is planning on having a spinal fusion. Lots of thoughts go through your mind as you prepare for the big day. Meanwhile, your surgeon is also giving the procedure some preplanning and preparation. Everything that can be done to minimize infection or other postoperative problems is considered. The surgeon will choose what type of bone graft material to use. Bone chips placed alongside and between the vertebral bodies help jump start the healing process and successful fu...
Surgeons removing synovial cysts from the spine have noticed some interesting things about these structures. Sometimes they are located quite a bit away from the joint they originate from. Sometimes they are on both sides of the joint. Sometimes they contain bits of joint cartilage, scar tissue, and even fragments of bone. These unusual findings led the researchers who wrote this article to study these cysts more closely and report on what they are made of and how they are formed.A synovial cyst...
Surgery for degenerative disc disease has traditionally been discectomy (removal of the disc) and spinal fusion. But with the new total disc replacement procedure, more patients are opting for this motion sparing technique. Fusion limits motion at the fused vertebral segments, whereas disc replacement tries to keep as much of the natural motion as possible. With either method, research has shown that total spinal motion is maintained, if not improved. How is that possible in the case of sp...
Bone grafts, attaching bone to bone, are a frequently performed surgery in the United States. Many of them are autologous, where a piece of bone is taken from the person who is getting the bone graft (auto = self). When doctors take bone for an autologous graft, it is most often taken from the iliac crest, part of the pelvis. The problem is, however, that when an autologous graft is done, the patient ends up with two surgical sites - where the bone came from and where the bone was grafted. Each ...
Two orthopedic surgeons wrote an article on spinal stenosis that was published in 2004. In this article, these same two physicians revisit that topic and update information on causes of spinal stenosis, anatomy, diagnosis, and treatment. Goals of treatment and the ideal patient for each type of treatment are presented.Spinal stenosis refers to narrowing of the spinal canal or the intervertebral foramina of the lumbar spine. The spinal cord travels down the spinal canal, so anything that narrows ...
What do we know about physical activity and low back pain? Is it a risk factor? Or a preventive aid? The authors of this study from The Netherlands suggest that too little or too much activity might be a risk factor for low back pain.
Piriformis syndrome: what is it? How do you get it? How do you know you have it? How do you get rid of it? What else do you need to know? That's the substance of this review article written by two well-known and well-respected Physical Therapists on the subject of piriformis syndrome.
Why do some people get back pain over and over while others recover without a single recurrence? That's the question these scientists asked in a study from Australia. They suspected that activity of the deep muscles in the back might be different in some people. This could be causing return bouts of back pain.
Surgeons at the Spine Institute (University Hospitals of Cleveland) are trying to find evidence to suggest bracing after spinal fusion for degenerative spinal disorders is advised. They would like to know if wearing a brace helps stabilize the spine and produce a better result.
Sometimes having low back pain can make even the simplest tasks difficult. Take for example, coming to a standing position from sitting. A loss of muscle power can make the sit-to-stand task much harder to accomplish. And that's a problem because the sit-to-stand motion is incorporated into many of our daily activities. What can be done about this?
New information from this study suggests that spondylolysis occurs more often than was once thought. Past estimates of its incidence relied on X-rays, which may not always show the defect. Updated rates of prevalence using CT scans suggest almost double the number of cases in the general population compared to what was previously reported.
According to this Japanese study, elite athletes who train for many years (from childhood on), are at risk for degenerative disc disease (DDD). Risk factors include participation in strenuous sports activities with specific postures and actions. A bout of severe low back pain during youth may also be a predictive factor of disc degeneration.
There's a commonly held belief that once you've had an episode of low back pain (LBP), you are liable to have another. Studies estimate that the recurrence rate for LBP can be as high as 84 per cent. But the authors of this study challenge that thinking. They point out how research in this area has been flawed.
Back pain leading to disability is an everyday problem for far too many people. In fact, chronic low back pain is the number one cause of disability among men and the number two most common cause of disability in adults of both sexes and all ages.
When a patient presents with pelvic pain and a history of trauma, the physician suspects pelvic instability. In this study, the use of X-rays taken with the patient standing on one leg called a single-leg stance was evaluated in the diagnosis of pelvic instability.
Scoliosis, a curvature of the spine occurs most often in older children and teenagers. But it can develop in older adults with serious complications. The cause is usually age-related degenerative changes in the spine. Sometimes there is no known cause. In this study, surgeons from the Department of Neurosurgery at the University of Virginia examine how often scoliosis occurs in older adults and the treatment needed.
Farming is a very physical job - from lifting heavy and awkward objects, pushing and pulling animals, equipment and objects, to working or riding with machinery that have strong vibrations. As well, there is a tremendous amount of pressure on the farmers to work within specific time frames (for planting, harvesting, and so on), which doesn't allow for them to rest or take time off when they feel they may need it. Because of the lifestyle, researchers have assumed that farmers would be at high ri...
Which is better? Surgery or nonsurgical care for lumbar disc herniation (LDH)? Surely by now enough studies have been done to identify the preferred choice. But, in fact, a review of five of the largest randomized controlled trials (RCTs) still couldn't answer the question.
In the last 30 years, as the Baby Boomers became adults, the management of low back pain (LBP) has changed. Baby Boomers were born between 1946 and 1964. Parents of Baby Boomers were more likely to expect the doctor to make all the decisions. But patients today are active consumers. This has resulted in a new concept of patient care called shared decision-making.
The authors of a Japanese study evaluated various factors that they thought could be associated with lumbar intervertebral disc degeneration. Lumbar intervertebral discs degenerate with normal aging. Degeneration of discs precedes lumbar disc herniation and lumbar spinal canal stenosis. Using magnetic resonance imaging, MRI, they were able to evaluate 1,347 intervertebral discs from L1/2 to L5/S1 in 270 subjects with a mean age of 68.4 years who volunteered for the study.
The authors of the study performed a literature search to evaluate the role of specific core muscle strengthening with Physical Therapy for low back pain, LBP, in golfers. They also evaluated the trunk flexibility and type of golf swing.
Physical Therapy is a common part of the treatment for chronic low back pain. Chronic back pain is defined as pain that lasts beyond the expected time for healing. This is usually after three months.
Medical experts know that an active rehab program after back surgery is helpful. Patients who have had a disc removed in the low back area tend to get better with active exercise. They often have less pain, more movement, and more function.
Low back injuries in athletes are often hard to treat. Medicine still doesn't have a good test to find out what's causing back pain. There is no one proven way to treat low back injuries in athletes. Nor is there any way to know for sure when an injury is fully healed so that the athlete can get safely back to competition.
Do back patients who expect treatment to help them get better than those who don't? Many doctors, Physical Therapists, and researchers think so. Scientists haven't been able to prove it yet. A new study from the University of California, Los Angeles, can shed some light on this topic.
People with chronic low back pain may see a Physical Therapist for treatment. The therapist uses tests of movement and strength to find out what's wrong. Changing the position of the spine is one way to help reduce painful symptoms.
Electric heating pads and other heat treatments can soothe low back pain. However, they either get too cold in the wee hours of the morning, or they get so hot that they can burn the skin.
Heat can soothe aches and pains. However, in the case of low back pain, heat treatments have never been shown to provide lasting pain relief. This is true of heating pads and other short-term heat treatments that patients use for a half-hour or so while resting. But these researchers tested what would happen if patients wore a 104-degree heat wrap for at least eight hours during normal daily activities. The results were impressive.
We use our "position sense" when we have to quickly adapt our body to changing or unexpected demands. It's the body's way of helping us stay upright when we run on uneven ground or jump into a floating canoe. It also helps keep our joints steady and safe from injury.
Walking is often recommended as good exercise for people recovering from low back pain (LBP). But doctors are not sure how LBP affects walking. This research tried to shed some light on the mechanics of walking in people with LBP.
Everyone wants to get "back to normal" after a bout with back pain. Athletes are especially eager to return to play after back surgery. This study may give some help to professional and Olympic athletes.
Many workers in industrialized nations are now seated workers. More and more jobs involve doing tasks while sitting down. Back pain may be linked to seated postures. In particular, the flexed curve in the low back and static muscle load are two major risk factors for disc problems.
Patients getting a spinal adjustment have come to expect a popping sound. But a study by a group of Physical Therapists reports that this popping is not necessary for a successful treatment
For years studies have shown few therapies that work in the treatment of chronic low back pain. Doctors have tried "usual care," which means rest, then activity, along with pain relievers.
Are you confused by the terms "manual therapy," "soft tissue mobilization," or "spinal manipulative therapy?" Doctors Swenson and Haldeman have taken the time in this report to define and describe each one of these treatments. They also looked at the research on spinal manipulative therapy (SMT). SMT is divided into three types of treatment offered by a chiropractor, osteopath or other medical doctor, or Physical Therapist.
"Lie on your right side. Let your left arm roll back. Now gently press your legs down against my hand here. That’s good. Hold. Hold. Relax." This is what you might hear a Physical Therapist say to you while performing a muscle energy technique (MET).
What do you think would happen if you had back pain? Would you get faster pain relief with manipulative treatment, exercises, and a doctor visit? Or would you do better if you just had an hour with the doctor? During this hour, you would get an exam, encouragement, and some instructions about posture, lifting, and stretching.
What do low back pain and a head cold have in common? They are the top two reasons for visits to the doctor. There's also no known cure for either one. With that in mind, researchers continue to look for a cure for the common cold and ways to treat low back pain.
Patients with low back pain (LBP) have one thing in common: they'd like to know what's causing the pain. Yet doctors are often at a loss to give answers to patients. We do know that two-thirds of all patients have chronic LBP caused by lumbar discs, the small joints on the back of the spinal column (the facet joints), or the sacroiliac (SI) joint.
What happens to muscle strength and size after back fusion? How do the results compare with the muscles of back pain patients going through an exercise program? Scientists in Norway are sorting this all out. In this study, back pain patients were divided into two treatment groups. One group received a lumbar fusion; the other was prescribed exercise and education.
Imagine 100 billion dollars. This is the annual cost of back care in the United States. The high rate of repeat back pain and chronic disability accounts for much of this price tag.
If you stand on a flat surface with your feet fully supported, your ankles do the work of keeping your body centered over your feet. But if you stand on a surface that is smaller than your feet, then the hips work extra hard to keep you upright on your feet.
Exercise is still the best treatment for chronic low back pain. Studies show it's safe and doesn't increase your risk of future injury. In fact, it's likely that a regular exercise program prevents future episodes of back pain. These are the results of a review of many studies done on exercise as a treatment for chronic back pain.
This is a follow-up study of 45 patients treated for chronic low back pain at the University of Iowa Spine Treatment Center. In the first study in 1992 patients were put in one of two groups. One group was in a multidisciplinary program. That means the group did Physical Therapy, aerobic exercise, and vocational counseling. There were also classes on many subjects about back pain.
Smoking is a risk factor for many diseases. It's also a risk factor for low back pain (LBP). This means if you smoke you're more likely to have LBP than someone who doesn't smoke. How do smokers with LBP measure up strength-wise compared to nonsmokers?
Low back pain (LBP) is a common problem in adults. As it turns out, adults are more likely to have back problems if they had back pain earlier in life. One in three teenagers (about 30 percent) will have back pain. LBP occurs again later for 88 percent of those teens. Verifying these figures and finding ways to prevent back pain are the goals of this study.
Everyone agrees that staying active is usually the best way to treat acute low back pain (LBP). There's still a question about the use of Physical Therapy, especially the timing of treatment. United States guidelines advise early Physical Therapy. Australia and Great Britain say it's best to wait and see what happens.
Many studies over the years have looked at the effect of exercise on low back pain (LBP). The results of these studies shows some benefit of general fitness exercise or strength training. In this study, Physical Therapists from Greece report on the effect of aerobic exercise on patients with chronic LBP.
Protecting the back from injury is a major focus of the Physical Therapists (PT). In this study PTs from Canada take data from five abdominal and two back extensor muscles. The measurements are recorded during a core strengthening exercise.
Research shows exercise works well for patients with back pain. The question is: what kind of exercise is best? So far there's little proof that one type of exercise is better than another. This study compares two kinds of exercise for patients with nonspecific back pain.
This report gives an updated review of studies done using acupuncture. All patients included were at least 18 years old. Everyone had nonspecific low back pain.
Low back pain (LBP) is a common problem and one for which we don't have a "one-size-fits-all" treatment. In this study researchers at a center for work rehabilitation in Switzerland compared two treatment methods for LBP.
Two facts are well-known about chronic low back pain (LBP). 1) Exercise helps. 2) People quit exercising after a while. In this study researchers from the University of Vienna in Austria look at the long-term effect of combining exercise with a motivational program for patients with LBP.
Physical Therapists need ways to measure the success of treatment. If pain is used as a measure, how much improvement is enough to say the treatment worked? In this study therapists used the standard numeric pain scale (NPS) with low back pain (LBP) patients to determine how much change was meaningful.
New stick-on heat wraps have been shown to help decrease back pain. They also decrease muscle soreness. But do they improve function or decrease disability when worn during exercise? That's the focus of this study.
Standing up and sitting down are important movements in our everyday lives. In this study, researchers show that hip and spine motion needed for these activities are affected by low back pain (LBP).
Physical Therapists treat low back pain (LBP) patients with a wide range of increased and decreased motion in the spine. Treatment choice is often based on the idea that a spine with too much motion (hypermobility) should be treated with stabilization exercises.
Patients with mechanical low back pain (LBP) of unknown cause are often lumped together. Everyone gets the same treatment. But a group of Physical Therapists suggest that patients with nonspecific LBP should be treated individually. Subgrouping patients during treatment gives better results.
Increased abdominal fat is common in the aging adult. Along with it comes an increased risk of low back pain (LBP). According to the results of this study, isolated strength training may help slow the effects of aging on the low back.
Researchers around the world are studying ways to treat chronic low back pain (LBP). Physical Therapy is often prescribed. The patient may be treated with manual therapy, which includes joint manipulation or the more gentle joint mobilization. Sometimes therapists combine manual therapy with exercises, heat, or electrical therapy. But what works best?
In this study two Physical Therapists (PTs) at the University of Wisconsin - Madison review the records of 133 patients treated for low back disorders. There were three goals:
There are many ways to treat low back pain. In this report, doctors from three large medical schools in the United States review the nonsurgical methods. Education, medication, activity and exercise are described and discussed. The use of Physical Therapy, massage, magnets, and manipulation are also included. Traction, injections, bracing, acupuncture, and behavioral therapy are other conservative treatment choices.
In this study, Physical Therapists assess the benefit of neutral zone (NZ) exercises to prevent low back pain. Exercises to preserve the NZ of lumbar motion keep the natural low back curve during movement and function. The natural curve is similar to the spine's position when in the upright or standing position.
In recent years researchers have discovered that fear-avoidance beliefs (FAB) are linked with chronic low back pain (LBP) and disability. FAB is observed in LBP patients who alter the way they move out of fear that movement will hurt. Two types of FAB have been identified. One is linked with general physical activity. The other is work-related.
Magnetic resonance imaging (MRI) and other imaging studies are not recommended for nonspecific low back pain (LBP). Even so, the use of these tests continues when they aren’t needed. Often treatment isn't any different for patients who have an MRI compared to those who don't.
Spinal stabilization exercises have become a popular choice for treating nonspecific low back pain (LBP). But is there any value added from these exercises over the usual Physical Therapy program?
Muscles regulate themselves during movement. Contraction and relaxation occur and change as the body moves and alters position. The multifidus, a deep muscle of the back is the focus of this study.
Low back pain (LBP) has become such a common problem that experts call it a national crisis. Most of the time, LBP goes away by itself. One proposed solution to this crisis is to ignore it. This concept is called demedicalization.
What kind of Physical Therapy (PT) program works best for lumbar spinal stenosis (LSS)? That's the topic of this study by a group of PTs from around the United States. Spinal stenosis is a narrowing of the spinal canal where the spinal cord is located. Anything that narrows the spinal canal can also put pressure on the spinal nerves as they exit the canal through special holes called the neural foraminae.
It's a well-known fact that low back pain (LBP) occurs in people with no obvious problems seen on X-ray or MRI. And it's also true that people with degenerative changes seen on imaging studies often have no symptoms at all. It would be helpful if people could have a baseline MRI done and kept on file. Then, if back problems come up, a second MRI could be done to compare any changes that have occured.
In this study, researchers asked the question, Does minor trauma increase the risk of serious low back pain (LBP)? They report the answer is No. This was the case even for people with risk factors for degenerative lumbar disc disease but no previous episodes of LBP.
Almost 800 adults participated in this study of low back pain (LBP). There were two goals:
In this study, patients with sciatica due to disc herniation were observed over a 10-year period of time. The goal of the study was to compare long-term outcomes between workers who received worker's compensation (WC) and those who didn't.
After 50 years of intense research on the origins of back pain, we still don't know where it comes from. But thanks to Alf Nachemson, M.D. we know much more than we used to. Dr. Nachemson, who died in December, 2006 was a leading researcher in the area of back pain.
Many people in the Western world experience chronic back pain that affects their quality of life and ability to work. Although researchers have been trying to find the best treatment for chronic back pain, study findings are conflicting about which is better: surgical or nonsurgical (conservative) treatment.
Lower back pain afflicts many people. Some statistics claim that people have a 65 percent to 85 percent chance of developing lower back pain at some point in their life. In addition, among those who do have back pain, anywhere from 28 percent to 75 percent experience relapses, often more than one. Since back pain can affect someone's ability to work and perform daily activities, and it is costly for the healthcare system, many researchers have tried to find ways to prevent back pain from occurri...
Better imaging technology has shown us that the brain changes in response to chronic pain. Scientists suspect changes in the structure of both the spinal cord and the brain occur. In fact, there may even be changes in the immune system. The result is an ongoing series of pain messages.
According to the results of two surveys done 10 years apart, chronic back pain is more common now than ever before. Eighteen per cent (18%) of U.S. workers report chronic pain while on the job.
There's an ongoing trend in medicine for evidence-based care. Instead of a feel-good-for-the-moment approach, there must be some proof that the treatment actually works.
Management, not treatment, is the new byword for patients with low back pain. Bed rest is no longer advised even for a day or two. Staying active is the number one piece of advice doctors now give their back pain patients.
Walking is good exercise. It is often the main part of an exercise program for people with low back pain (LBP). But if it hurts to walk, back pain sufferers are less likely to follow through with the program.
Back and neck pain are among the most common complaints in industrialized or developed countries. Statistics show that chances of having back pain within a one-year period is anywhere from 15 percent to 56 percent, depending on the country in which you live. For neck pain, the chances are between 12 percent and 34 percent. However, neck pain and back pain often go hand in hand.
In this article, orthopedic surgeons from the New York University/Hospital for Joint Diseases present a review of osteoporosis. They outline who is most likely affected. They also discuss how to diagnose the problem, and how to treat the condition. In addition, ways to prevent osteoporosis are presented.
Back and leg pain (sciatica) affect many Americans every year. Despite how common the disorder is, the best treatment for the problem still remains unknown. In this study, the results of two different treatments are compared.
In this study, researchers asked the question: what is it that causes disc degeneration the most? Is it what we do (occupational, physical activities)? Or is it how we are put together (size, weight, shape)? For example, is it age, body weight, or lifelong loading from daily activities? Or is it the size of the disc or the person's lifting strength?
Physical Therapists (PTs) around the world have joined the search for a treatment method that can help patients with chronic low back pain (LBP). In this study, therapists from England compare the use of patient education with group therapy using an approach called cognitive behavioral therapy (CBT).
The search continues for a way to predict and prevent chronic low back pain (CLBP). One theory is that CLBP leads to physical deconditioning. Deconditioning means loss of strength, endurance, and aerobic capacity. Deconditioning is likely to result in more pain. But this theory has never been proven.
It's been assumed for years that a decline in physical activity leads to deconditioning and that deconditioning can result in chronic low back pain (CLBP). But studies have not been able to prove this point right or wrong. However, research does show that declining physical fitness is more likely to be related to disability.
When doctors want to know whether or not a specific treatment is effective, they look at a collection of studies and compare the results. The most reliable data comes from a specific type of study called random controlled trials (RCTs).
Scoliosis or curvature of the spine is often thought of as a childhood problem. But more and more, older adults are experiencing this condition, too. Studies show that bone spurs and degenerative disc disease probably start the process that leads to scoliosis.
Over 20 years ago, a group of researchers led by T. G. Mayer, M.D. proposed a new approach to chronic low back pain (LBP). The focus moved away from bedrest to a more active treatment approach. The new program was called a functional restoration program.
Orthopedic surgeons are aware of the hip-spine syndrome but no one has ever studied it. The hip-spine syndrome refers to low back pain (LBP) that occurs as a result of hip osteoarthritis (OA). This is the first study to show the positive effect of hip replacement on low back pain.
Sciatica, also known as the lumbrosacral radicular syndrome (LRS) can be a painful and disabling problem. Pressure on the nerve as it leaves the spinal cord can lead to the back and leg pain common with sciatica.
Back pain in older adults is a common problem. In fact, up to half of all adults over the age of 65 report some type of body pain. Pain of any kind can decrease function and threaten the independence of seniors.
n Finland, researchers have been conducting various studies on 300 pairs of male twins. Using the data collected, scientists can look for genetic causes of health-related issues.
Studies show that back pain sufferers go on to develop chronic pain and disability when fear-avoidance beliefs (FABs) are present. FAB refers to the idea that the patient believes activity will cause another injury and more pain. This is a negative interpretation of painful symptoms that is often in error.
Heat is a common modality to use for low back pain (LBP). But how well does it work? How long does it last? If low-level heat reduces pain and promotes relaxation, how does it do this?
Advancing technology has provided a new research tool for rehab specialists. It's called rehabilitative ultrasound imaging (RUSI). This type of ultrasound can be used to assess muscle contraction and function.
In this case report, Physical Therapists measure the response of a single muscle to treatment using spinal manipulation for low back pain (LBP). The patient was a 33-year old man who had a long history of LBP and leg pain.
Studies show that psychosocial distress is linked with chronic low back pain (CLBP). People who are depressed, anxious, or stressed are at greater risk for CLBP. Fear, uncertainty, anger, and hostility are other ways distress is expressed.
Many occupations and daily activities require prolonged sitting. This may be a cause of low back pain and sitting discomfort. The authors studied the use of a fixed lumbar support compared to a Continuous Passive Movement (CPM) lumbar support. The cushions had the same inflation pressure in sitting. Thirty-one male healthy subjects were required to sit in the same chair for a two hour period on three consecutive days. One of the days, there was no support, another a fixed lumbar support, and the...
For years, scientists have tried to figure out what treatment works best for patients with low back pain (LBP). Physical Therapists have joined that effort by studying various types of exercises that might help.
Core training or core stabilization exercises are very popular right now. Many people do these exercises after a back injury or for back pain. Others do them in hopes of preventing a back problem. Do they work? Who should do them?
Over the years, the treatment of acute low back pain (LBP) has changed from bed rest to activity. This advice may help prevent acute pain from becoming chronic pain.
Studies show over and over that staying active and exercising are the first steps to take in treating low back pain (LBP). But what kind of exercises work best? Are aerobic programs ideal? What about strength training? Perhaps a more specific approach such as the McKenzie exercises should be followed?
Studies show that a multidisciplinary approach is best for patients with chronic low back pain (LBP). Multidisciplinary involves Physical Therapy, behavioral and psychologic counseling, and change in psychosocial factors. A chronic stage is defined as patients with pain lasting three months or more.
People with back pain don't always agree on what improvements suggest they are better. Is a 10 per cent decrease in pain enough to say, I'm better now? How much improvement in function suggests that treatment is working well?
Chronic lower back pain is one of the most common chronic pains in Western society and results in high economic and social costs. Many studies have been done to assess and improve the quality of life (QoL) of patients with chronic lower back pain.
Chronic low back pain, a common ailment among older adults, can result in depression, decreased appetite, difficulty sleeping, and decreased quality of life. To manage this pain, researchers say that up to 1/3 of older adults have used alternative, or complementary, medicine, such as meditation.
The authors of this study worked in collaboration with the College of Physicians and the American Pain Society to develop evidence-based guidelines on low back pain, evaluating how well different therapies work. They conducted an evidence-based review of studies published between 1966 and 2006.
Getting back to work after a low back injury can be a challenge for some patients. Work-related injuries can lead to fear of re-injury. Workers may think they cannot perform their job again without pain. This is called fear avoidance behavior (FAB).
Spinal manipulation (SMT) to treat lower back pain (LBP) has been performed for generations, dating as far back as 2700 BC, it is thought. Since 1895, SMT has been primarily the domain of chiropractics, when it became a profession. With the increasing prevalence of lower back pain in the Western world, SMT and spinal mobilization (MOB) - similar to SMT but without the thrust - has become increasingly popular as a treatment.
There are many treatments and therapies available to help manage chronic lower back pain (CLBP), with some working for some patients and not for others. One treatment that is gaining popularity is massage, likely one of the earliest and most primitive methods of treating pain.
Chronic lower back pain (CBP) is increasingly common in the Western world. With the commonality of the back pain comes an abundance of pain relief options - so many that it can be confusing and difficult for patients to be properly informed of the options, making it virtually impossible to make informed decisions. The issue reaches beyond the patient to the treating physicians and the third-party payers as they all try to find the best and most economical way of treating their patients.
The North American Spine Society has published a special issue of their journal on nonsurgical ways to treat chronic low back pain (CLBP). The goal was to bring us up-to-date on many types of treatments that have some clinical benefit to patients. In this article, medicine-assisted manipulation (MAM) was reviewed.
The cost of health care is rising every year in the United States. And part of that economic burden is the management of chronic low back pain (CLBP). Efforts are being made to find out what kind of nonoperative treatment might work best for CLBP. In this report, doctors and therapists from Mayo Clinic bring us up to date on traction therapy. Does it work? How? What's the evidence to support this treatment approach?
Patients looking for nonoperative ways to treat chronic low back pain (CLBP) might want to consider cognitive behavioral therapy (CBT). CBT is a way to change behavior by changing the way a patient thinks about his or her back pain. In this review of CBT, experts in psychology at the University of Texas (Arlington) offer a summary of CBT.
There are many different ways to treat chronic low back pain (LBP). Not all work equally well. Some seem to fit certain patients better than others. There is a wide range of symptoms and response to treatment observed with the many people affected by chronic LBP.
So many people are affected by back pain that it has become the focus of intense study and research. In the last 10 years, a new appreciation has formed for the role of psychosocial issues in chronic low back pain (LBP).
Amid the many treatments available for the management of chronic lower back pain (CLBP), watchful waiting remains an approach for patients who do not have acute back pain nor injuries or disabilities that would deteriorate and cause more harm if left untreated.
Many risk factors appear to contribute to the development of chronic lower back pain (CLBP), including lifestyle factors, such as smoking, weight, and exercise. These modifiable risk factors are considered to be an integral component for the prevention and treatment of CLBP.
Acupuncture, a treatment that goes back over 2000 years, is gaining popularity as an alternative treatment in the Western world, particularly for treatment of chronic lower back pain (CLBP). There are different styles of acupuncture available: Japanese Meridian Therapy, French Energetic acupuncture, Korean Constitutional acupuncture, and Lemington Five Elements acupuncture. Other forms have also been created.
In 1969, the Swedish Back School began with a goal of helping patients learn about spinal anatomy and physiology, as well as ergonomics. These back schools are now used throughout the Western world to help patients cope with chronic lower back pain (CLBP).
Scientists haven't been able to prescribe the perfect exercise program for everyone with low back pain (LBP). That may be because there is a wide range of exercises that can be done for the back. And no one has been able to nail down how much exercise, how often, or the intensity with which they should be done.
The latest craze in exercise programs is core training, also known as core stabilization or lumbar stabilization. But what does it do? And does it really work? Doctors and Physical Therapists at the University of Washington in Seattle reviewed available research to find out some answers.
The authors reviewed available random controlled trials and controlled clinical trials evaluating the efficacy of Physical Therapy modalities in the treatment of chronic low back pain (CLBP). These modalities included three electrotherapeutic modalities to include transcutaneous electrical nerve stimulation (TENS); electrical muscle stimulation (EMS); and interferential current (IFC). Physical agents that were evaluated included ultrasound, hot packs, and cold packs.
Researchers around the world are trying different forms and combinations of exercise and other treatment approaches to solve the problem of chronic low back pain (CLBP). This study was done in the Netherlands by a group of psychologists and rehab specialists.
Many research studies have been focused on patients with chronic low back pain (CLBP). It's clear that exercise is the first treatment choice. But what kind of exercise? And should it be used alone or after some other treatment?
If you've got a herniated disc, should you have it removed? Does the location and type of herniation make a difference in how your back feels? These are the two questions studied and discussed in this article.
Spondylolisthesis is a condition that usually affects the lumbar spine. It occurs when one of the vertebrae slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may be pulled or pinched causing nerve irritation and pain.
While many patients report the advantage or disadvantage of certain mattresses, studies have been inconclusive. The authors of the study compared three different types of mattresses in persons with chronic low back pain. They investigated their effect on back pain, leg pain, activities of daily living, and hours of sleep.
Physical Therapists (PTs) are involved in an ongoing effort to find out what works best to treat nonspecific low back pain (LBP). Nonspecific refers to the fact that no known cause can be found for the pain.
In this article, two family medicine physicians offer a prescription for conducting a quick (10-minute) exam of the low back. The target population is adults with acute low back pain (LBP). This information is helpful since the majority of patients with LBP don't have a clear cause of their painful symptoms. And most physicians don't have the luxury of keeping hour-long appointments with their patients.
Patients with chronic low back pain (LBP) may fear re-injury enough to avoid movement. This concept is called kinesiophobia (fear of movement). A constant cycle of pain, fear, disuse, and depression can be the result of kinesiophobia.
Chronic low back pain (CLBP) can really decrease a person's quality of life. There are many ways to approach the treatment of CLBP. Back school is one method that's been around since the late 1960s.
Healthcare costs for patients with low back pain (LBP) have climbed into the billions of dollars each year. And that's the direct cost. It doesn't include the indirect cost due to loss of productivity, work-time, or wages.
Do you really have to do those exercises after a lumbar discectomy (disc removal)? According to this study, yes -- if you want to get back to work sooner, see your doctor less often, and feel better in general.
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