Sports Spine Specialist Chiropractic Team: Athletes strive to achieve their body’s maximum performance by participating in numerous training regimens consisting of strenuous exercises and physical activity and ensuring they meet all of their body’s nutritional requirements. Through proper fitness and nutrition, many individuals can condition themselves to excel in their specific sport. Our training programs are designed for athletes that look to gain a competitive edge in their sport.
We provide sport-specific services to help increase an athlete’s performance through mobility, strength, and endurance. Occasionally, however, the excess workouts can lead many to suffer injuries or develop underlying conditions. Dr. Alex Jimenez’s chronicle of articles for athletes displays in detail the many forms of complications affecting these professionals while focusing on the possible solutions and treatments to follow to achieve overall well-being.
As individual bodies age, the nerves and muscles begin to degenerate, especially in the lower spinal region. This can cause sciatic pain and muscle weakness. Elderly sciatica is very common as the nerves and muscles have gone through a lot. Bending, lifting, carrying, reaching, twisting, and natural wearing and tearing make the sciatic nerve and surrounding muscles prone to injury. For overweight seniors, the risk of developing sciatica is higher.
Elderly Sciatica
The main reason for elderly sciatica is that as the body ages, the discs/cartilage between the vertebrae/bones in the spine dry out, losing their cushioning ability, which can lead to the bones shifting out of place more easily, rubbing against each other, and compressing nerves. On average, the body loses about 1 centimeter in height every ten years after 40.
Risk Factors
Diabetes
Diabetes affects the entire body.
Not keeping blood sugar in check can cause widespread symptoms that affect the nerves and organs.
Individuals with diabetes have an increased risk of developing sciatica and other nerve-damaging disorders.
Genetics
If spinal conditions are part of family medical history, there is an increased risk of developing sciatica.
With chiropractic, elderly individuals can attain better quality sleep, improved mood, and increased energy levels.
A chiropractic physical therapy team can develop a specialized/customized treatment plan for preventive and palliative care.
Body Composition
Sarcopenia
Sarcopenia affects the elderly population’s mortality, cognitive function, and quality of life. As the elderly population is living longer, preservation of lean mass becomes an integral part of maintaining an individual’s independence. Loss of muscle in the arms and legs is linked to decreased mobility, increased risk of falls, and prolonged hospital stays. Falls and fractures often result in a cycle of muscle deterioration. InBody can help track body composition changes and help to minimize muscle wasting and risk of impaired mobility.
References
Aggarwal, Sameer, and Nityanand. “Calcium and vitamin D in postmenopausal women.” Indian journal of endocrinology and metabolism vol. 17,Suppl 3 (2013): S618-20. doi:10.4103/2230-8210.123549
Dougherty, Paul E et al. “The role of chiropractic care in older adults.” Chiropractic & manual therapies vol. 20,1 3. 21 Feb. 2012, doi:10.1186/2045-709X-20-3
Ferreira, Manuela L, and Andrew McLachlan. “The Challenges of Treating Sciatica Pain in Older Adults.” Drugs & aging vol. 33,11 (2016): 779-785. doi:10.1007/s40266-016-0404-z
Kherad, Mehrsa et al. “Risk factors for low back pain and sciatica in elderly men-the MrOS Sweden study.” Age and aging vol. 46,1 (2017): 64-71. doi:10.1093/ageing/afw152
Volleyball is a dynamic game that requires players to be fast on their feet. Players have to be able to quickly shift into various position/s, make quick movements in any direction quickly and reach the ball. Volleyball strength workouts focus on power development and maintaining safe positions when exploding through the plays. Many players include resistance training exercises in their training programs to maximize power and set a solid foundation.
Volleyball Strength Workout
A well-rounded volleyball workout will help players strengthen and maintain optimal body health.
A recommended exercise that can be done with a resistance band.
The exercise does not require a lot of space, so it can be done almost anywhere.
It is recommended to do two-three sets of 10-15 reps.
It is recommended to consult a professional trainer that can create a diverse fitness program to make exercising/training/working out much more enjoyable.
Body Composition
How Aerobic and Resistance Training Interact
The body adjusts differently to various types of exercise. Aerobic and resistance training each tells the body to adapt in different ways. Both are important for healthy body composition, and when done in combination, it is known as concurrent training. Aerobic is best for losing fat, resistance training builds muscle that keeps the body functioning throughout the day. However, molecular mechanisms involved in aerobic and resistance adaptations can interfere with each other if not appropriately planned. Two steps to minimize any possible interference and maximize aerobic/resistance benefits:
Nutrition
Adequate protein intake is vital for muscular adaptation from resistance training.
It stimulates muscle protein synthesis after concurrent training.
After workout sessions, consume at least 25g of high-quality protein to achieve strength and hypertrophy improvements.
Recovery
When doing both aerobic and resistance training on the same day, maximize recovery time between the sessions.
Strength and aerobic fitness gains are low when the two are separated by 6 hours or less.
Twenty-four hours between sessions is the recommended time, especially if the priority is on endurance.
References
Camera, Donny M et al. “Protein ingestion increases myofibrillar protein synthesis after concurrent exercise.” Medicine and science in sports and exercise vol. 47,1 (2015): 82-91. doi:10.1249/MSS.0000000000000390
Cools, Ann M et al. “Prevention of shoulder injuries in overhead athletes: a science-based approach.” Brazilian journal of physical therapy vol. 19,5 (2015): 331-9. doi:10.1590/bjpt-rbf.2014.0109
Pereira, Ana et al. “Training strategy of explosive strength in young female volleyball players.” Medicina (Kaunas, Lithuania) vol. 51,2 (2015): 126-31. doi:10.1016/j.medici.2015.03.004
Ramirez-Campillo, Rodrigo et al. “Effects of Plyometric Jump Training on Vertical Jump Height of Volleyball Players: A Systematic Review with Meta-Analysis of Randomized-Controlled Trial.” Journal of sports science & medicine vol. 19,3 489-499. 13 Aug. 2020
Seminati, Elena, and Alberto Enrico Minetti. “Overuse in volleyball training/practice: A review on the shoulder and spine-related injuries.” European journal of sports science vol. 13,6 (2013): 732-43. doi:10.1080/17461391.2013.773090
Silva, Ana Filipa et al. “The Effect of Plyometric Training in Volleyball Players: A Systematic Review.” International journal of environmental research and public health vol. 16,16 2960. 17 Aug. 2019, doi:10.3390/ijerph16162960
Villareal, Dennis T et al. “Aerobic or Resistance Exercise, or Both, in Dieting Obese Older Adults.” The New England journal of medicine vol. 376,20 (2017): 1943-1955. doi:10.1056/NEJMoa1616338
Healthy sleep plays a vital role in the body’s overall health, as it ensures muscle growth, recovery, and illness prevention. This is especially true for home D.I. Yers’ fitness enthusiasts, weekend warriors, athletes, and physically active individuals. When sleeping, the body goes into recovery mode, releasing hormones and other chemicals to repair and restore muscle. A healthy night’s sleep provides the rest the mind and body need to perform at optimal levels.
Healthy Sleep
Sleep is vital for recovering from workouts. This could be construction work, exercise, gardening, sports, landscaping, any activity that uses bodyweight or works against some form of resistance. The muscles cannot repair themselves properly without proper sleep. Sleep aids the muscles in releasing protein-building amino acids, helping them grow in size and strength.
Growth hormone is released during non-REM sleep that stimulates tissue growth and repairs muscle.
During REM or rapid eye movement sleep, blood pressure drops, breathing slows and deepens, the brain relaxes, and blood supply to the muscles increases, feeding them oxygen and nutrients.
Unhealthy Sleep
Sleep maintains the muscles’ sharpness, coordination, function, and muscle movement patterns that improve physical performance. The body needs to sleep for at least 7 hours a night for muscles to grow properly. Not getting healthy sleep decreases protein synthesis activity and increases the activity of degradation that leads to muscle loss.
Less Sleep Leads To Eating More
Hormonal changes occur when the body sleeps less, causing individuals to feel hungry more often, increasing the amount of food taken in because after eating, the body does not feel full right away, so the individual continues to eat. Without sleep, the body decreases the production of a hormone that indicates when the body is full and activates a hormone that causes hunger. Insufficient sleep also lowers the body’s sensitivity to insulin. Because of this, the muscle fuel glycogen is not adequately replenished. Without the regular restoration of glycogen, individuals have less energy, insulin sensitivity decreases, increasing the risk of diabetes.
Physical Health
Unhealthy sleep also impacts overall physical health. Individuals that do not get healthy sleep have an increased risk of developing:
Sugar raises blood sugar, which triggers the pancreas to release insulin, fueling the cells causing overstimulation.
Eliminating sugar after dinner can help the body fall asleep.
References
Dattilo, M et al. “Sleep and muscle recovery: endocrinological and molecular basis for a new and promising hypothesis.” Medical hypotheses vol. 77,2 (2011): 220-2. doi:10.1016/j.mehy.2011.04.017
Morselli, Lisa et al. “Role of sleep duration in the regulation of glucose metabolism and appetite.” Best practice & research. Clinical endocrinology & metabolism vol. 24,5 (2010): 687-702. doi:10.1016/j.beem.2010.07.005
Murray, Bob, and Christine Rosenbloom. “Fundamentals of glycogen metabolism for coaches and athletes.” Nutrition reviews vol. 76,4 (2018): 243-259. doi:10.1093/nutrit/nuy001
Stretching Fundamentals: Stretching benefits the body by keeping the muscles flexible, strong, healthy, and able to maintain optimal physical performance. As with any other discipline stretching correctly requires using the proper form, correct technique, and practicing regularly. The angles need to be accurate; the body has to move at the right speed and maintain correct posture. The focus should be moving the joint as little as possible as the muscle/s stretch and elongate.
Stretching Fundamentals
Stretching should become a daily activity that turns into a healthy habit. The muscles need frequent maintenance from daily/nightly bending, twisting, reaching, carrying, and lifting work. This is especially true for individuals dealing with constant soreness, aches, pains, and problems with tight, tense, and stressed-out muscles. When the body is stressed, heart rate increases, and individuals tend to tighten up. Stretching benefits include:
Stress relief.
Increased muscle blood flow.
Increased body flexibility.
Helps joints move through their full range of motion.
Improves performance in physical activities.
Decreases soreness, aches, and pains.
Injury prevention.
Improves posture.
Improves sleep.
Preps the body for exercise and activities.
Improves mental health.
Human nature is to take the path of least resistance, which makes the body feel flexible and comfortable. This is a common reason individuals consider stretching unnecessary or too painful to engage in. However,stretching fundamentals need to be maintained as stretching carelessly or poorly can negatively affect other muscles and joints and worsen injuries/conditions.
Guidelines
To stretch safely, it is recommended to do a proper warm-up, stretch slowly, working the right muscles and joints. The guidelines make stretching safer, more effective, and increase body awareness.
Warm-Up
Warming the muscles increases blood flow.
Warming up muscles before physical activity/workout is crucial for preventing injuries and maximizing effectiveness.
Dynamic stretching involves moving into and out of positions through a full range of motion rather than holding a stretch for a prolonged period.
Dynamic stretches are recommended to be held for 2-3 seconds for 4-6 repetitions.
Take It Slow
Stretching out too fast can make the body think that the muscle is about to get torn or injured.
To protect the muscle, it contracts, preventing it from reaching the full stretch.
This is why the correct technique needs to be observed.
A couple of degrees in the wrong direction can mean the difference between a healthy stretch and pulling a joint capsule causing injury.
Body Composition
Muscle Recovery
When engaged in physical activity, exercise, or working, microscopic tears are happening to muscle cells. Because of the body’s stress and fatigue, hormone and enzyme levels fluctuate, and inflammation increases. This helps in fat loss, increases metabolism, increases strength and muscle growth. However, these benefits only happen with proper recovery. Different types of recovery include:
Immediate Recovery
These are the quick moments’ in-between physical movements.
For example, the time between each stride when jogging.
Short-Term Recovery
This is the time between activities or sets of exercises.
For example, the rest periods between doing a heavy job or sprint intervals.
Training Recovery
This is the time between when one workout or job ends, and the next begins.
There is no one size fits all, as everyone’s body is different; it is recommended to consult with a trainer or fitness expert and experiment with what feels right.
For some individuals, 24 hours is enough.
For others, it can take 48 or 72 hours to feel fully recovered.
Other factors that affect recovery are:
Age
Fitness level
Work/exercise intensity
Diet
Sleep
References
Behm, David G, and Anis Chaouachi. “A review of the acute effects of static and dynamic stretching on performance.” European Journal of applied physiology vol. 111,11 (2011): 2633-51. doi:10.1007/s00421-011-1879-2
Freitas, S R et al. “Stretching Effects: High-intensity & Moderate-duration vs. Low-intensity & Long-duration.” International journal of sports medicine vol. 37,3 (2016): 239-44. doi:10.1055/s-0035-1548946
Hotta, Kazuki et al. “Daily muscle stretching enhances blood flow, endothelial function, capillarity, vascular volume and connectivity in aged skeletal muscle.” The Journal of physiology vol. 596,10 (2018): 1903-1917. doi:10.1113/JP275459
Kataura, Satoshi et al. “Acute Effects of the Different Intensity of Static Stretching on Flexibility and Isometric Muscle Force.” Journal of strength and conditioning research vol. 31,12 (2017): 3403-3410. doi:10.1519/JSC.0000000000001752
Tremors are extremely rare, but they can result from spinal compression and not necessarily a brain condition like Parkinson’s disease. Tremors are abnormal, involuntary body movements with various causes, most of which are connected to the brain and not the spine. A study reports that more than 75% of individuals with Parkinson’s experienced a resting tremor, and about 60% experience tremors while moving. Sometimes the spine is the contributor caused by compression of the spinal cord.
Spinal Compression Study
A 90-year-old man was hospitalized after having tremors, with Parkinson’s being the initial diagnosis. The tremors progressed to the point where the man could not feed himself or walk without support. The case became the focus of a medical report published by physicians in the Department of Orthopaedic Surgery, Division of the Spine, Singapore Tan Tock Seng Hospital. Along with the tremors, symptoms progressed to:
Difficulty with fine motor skills like buttoning a shirt.
However, it was ruled out because the patient was not presenting with other Parkinson’s symptoms.
For individuals with cervical spondylotic myelopathy tremors, surgery can be used to help the condition. However, with cervical myelopathy, there is often some permanent damage. Individuals have shown that post-surgery and decompression, symptoms still present, maybe not as much, but there will be a need for a symptom management plan.
Prevention
The best way to prevent tremors associated with cervical spondylotic myelopathy is to minimize the strain on the spine that can lead to herniated discs and/or other spinal injuries. The discs in the spine degenerate, dry out and start cracking with age, increasing the risk of rupture. If a tremor develops, contact a doctor, spine specialist, or chiropractor to help diagnose the condition. These doctors can perform physical and neurological tests to determine the cause and treatment options.
Body Composition
Aging Health
Steady weight gain throughout life can lead to adult-onset diabetes. This is partly caused by having more body fat and progressive muscle loss. Loss of skeletal muscle mass is linked to insulin resistance that involves:
The less muscle is available, the less insulin sensitive the body becomes.
As insulin sensitivity decreases, the body becomes more resistant, increasing risk factors for type II diabetes.
This can lead to osteoporosis, where the old bone is reabsorbed more and less new bone is created.
Both men and women can experience decreased muscle mass that can lead to:
Thinner bones
Weaker bones
Increased risk of osteoporosis and severe injury from falls.
To help prevent these issues, it is recommended to:
It is recommended to space out protein intake across meals rather than consuming it all at once. This helps to ensure the proper amount is acquired.
Monitoring body composition regularly can help minimize muscle mass loss and fat mass gain as the body ages.
A regular strength training routine will help strengthen bones muscles and maintain optimal circulation.
References
Heusinkveld, Lauren E et al. “Impact of Tremor on Patients With Early Stage Parkinson’s Disease.” Frontiers in neurology vol. 9 628. 3 Aug. 2018, doi:10.3389/fneur.2018.00628
Jancso, Z et al. “Differences in weight gain in hypertensive and diabetic elderly patients primary care study.” The Journal of nutrition, health & aging vol. 16,6 (2012): 592-6. doi:10.1007/s12603-011-0360-6
Srikanthan, Preethi, and Arun S Karlamangla. “Relative muscle mass is inversely associated with insulin resistance and prediabetes. Findings from the third National Health and Nutrition Examination Survey.” The Journal of clinical endocrinology and metabolism vol. 96,9 (2011): 2898-903. doi:10.1210/jc.2011-0435
Tapia Perez, Jorge Humberto et al. “Treatment of Spinal Myoclonus Due to Degenerative Compression Myelopathy with Cervical Spinal Cord Stimulation: A Report of 2 Cases.” World neurosurgery vol. 136 (2020): 44-48. doi:10.1016/j.wneu.2019.12.170
Sports-specific performance training is an approach to develop an athlete’s full potential in their sport. This involves three different factors: physical, technical, and experience. Physical ability is the exercise physiology that consists of strengthening and conditioning the body to handle the conditions of the sport. This includes:
Strength
Power
Speed
Endurance
Mobility
Stability
Flexibility
Balance
Technical ability involves the skill sets needed for the sport. This includes:
Running
Jumping
Kicking
Throwing
Catching
Hitting
Sliding
And finally is the athlete’s experience. This takes the knowledge, combined with the physical and technical abilities brought together to perform at optimum levels. However, it all begins with physical ability that needs to be developed. Even naturally gifted individuals need to develop their physical ability.
Sports Specific Performance Training
Strength & conditioning objectives are to develop the whole athlete. This involves:
An athlete’s health takes into consideration their body composition and current or past injuries. Along with injuries, the athlete’s mobility, flexibility, and stability are examined to determine if these were among the contributors or conditions that caused or could lead to an injury. Strength & conditioning is used so an athlete can return to play and allow them to be more resilient to injuries. Maintaining the body’s health means:
Keeping track of nutrition by making healthy food choices.
Maintaining proper hydration levels.
Allowing the body to recover from training thoroughly.
Keeping the body loose and flexible through chiropractic sports massage or a personal training therapist.
Stability is the coordination of muscle action that allows a joint to remain in the proper position during movement.
If an athlete is mobile and flexible but not stable, it increases the risk of sustaining an injury. The same can be said of an athlete with stability but limited mobility.
Athletic Mindset
An athlete’s mindset can win or lose games.
Athletes are encouraged to push themselves to see what they are capable of, which relies on mental strength.
Athletes that doubt their ability become their own worst critics and hold themselves in low self-esteem tend to underperform or become overly cautious when competing.
This is where a sports psychologistcan help an athlete overcome any confidence issues.
Athleticism
Developing athleticism involves strength, power, speed. These physical attributes allow athletes to perform within their technical and strategical abilities.
It is recommended to spend 10-15 minutes warming up with each sports-specific performance training session. The warm-up:
Speed training addresses linear, lateral, and multi-directional speed. The objective is to keep athletes learning and developing better reaction skills while maintaining high-quality movement. Speed training can last 10 to 15-minutes with the number of repetitions.
Strength training follows an individualized system for each athlete based on an initial evaluation. The objective is to eliminate any weaknesses that an individual may have and develop functional strength, giving the athlete the ability to take that strength onto the field, court, mat, etc.
It is essential to understand how the body moves. Kinesiologyand programming parameters involve – sets, repetitions, overall training volume, and the body’s response to the stimulus.
Body Composition
Exercise and Blood Pressure
Blood pressure typically rises naturally as the body ages. The American Heart Association recommends individuals get at least 150 minutes of moderate-intense aerobic exercise or 75 minutes of vigorous aerobic activity each week. This can be split up into 30 minutes per day on at least five days a week or in 10 minute short sessions throughout the day. Aerobic exercise can include:
Walking
Dancing
Running
Cycling
Hiking
Swimming
Resistance Training
Research suggests that resistance training with bands or weights can supplement aerobic exercise to reduce blood pressure. It is recommended to complete 2 to 4 sets of 8 to 12 repetitions for each major muscle group during workouts. It is recommended that resistance training be spaced out throughout the week to limit the potential muscle soreness that can lead to injury. Resistance training can include:
Weight machines like chest press, shoulder press, etc.
Bahr, R, and T Krosshaug. “Understanding injury mechanisms: a key component of preventing injuries in sport.” British journal of sports medicine vol. 39,6 (2005): 324-9. doi:10.1136/bjsm.2005.018341
Iaia, F Marcello et al. “High-intensity training in football.” International journal of sports physiology and performance vol. 4,3 (2009): 291-306. doi:10.1123/ijspp.4.3.291
Jeukendrup, Asker E. “Periodized Nutrition for Athletes.” Sports medicine (Auckland, N.Z.) vol. 47,Suppl 1 (2017): 51-63. doi:10.1007/s40279-017-0694-2
Kraemer, William J, and Nicholas A Ratamess. “Fundamentals of resistance training: progression and exercise prescription.” Medicine and science in sports and exercise vol. 36,4 (2004): 674-88. doi:10.1249/01.mss.0000121945.36635.61
Nagorsky, Eugen, and Josef Wiemeyer. “The structure of performance and training in esports.” PloS one vol. 15,8 e0237584. 25 Aug. 2020, doi:10.1371/journal.pone.0237584
Post spine surgery physical therapy or PT is the next phase after a discectomy, laminectomy, fusion, etc., to gain optimal mobility and ease the transition for a full recovery. A chiropractor and physical therapist team will help with proper muscle training and activation, pain and inflammation relief, postural training, exercises, stretches, and educate the individual on an anti-inflammatory diet. Physical therapy post spine surgery reduces:
Scar tissue
Inflammation
Muscle weakness
Muscle tightness
Joint stiffness
The therapy also identifies and treats any issues that caused or contributed to the spinal damage/injury. A study found physical therapy to improve postoperative ambulation, pain, disability, and decreased surgical complications.
Post Spine Surgery Physical Therapy Goals
Physical therapy goals are to return the individual to full function before chronic pain or injury. These include:
Decrease pain and stress around the surgical site.
Loosen and stretch the muscles surrounding the surgical site.
Strengthen the back and neck muscles.
Stabilize the back and neck muscles.
Learn to move around safely.
Prepare for everyday physical activities like standing up or sitting down, lifting, and carrying objects.
Improve posture.
The therapy team will develop a customized treatment/rehabilitation plan as well as post-surgical recovery at home to help the individual and family to understand what to expect, including psychological factors like not wanting to perform the exercises or stretches to avoid pain, frustration, anger, depression, and wanting to give up. However, individuals can maximize the benefits to ensure an optimal outcome before surgery by pre-conditioning identifying structural and functional issues contributing to the injury.
Physical Therapy Involves
Therapy can be done at home, in a hospital or rehab setting, or at a chiropractic/physical therapy clinic. Therapists use:
A physical therapy session can last 45 minutes to an hour. It’s essential to discuss hopes and expectations post-surgery and after the therapy has finished. The therapists will explain the healing process, the treatment progression, and any questions a patient may have. Understanding the treatment process will help the individual want to engage in the treatment plan. The therapist team will also interface with the surgeon to prevent adverse outcomes.
Optimal Health
The physical therapy team will help the individual feel better with each session and stay motivated. Having a solid relationship with the therapy team makes it easier to share goals, worries, and challenges that the team can adapt to as progress is made. To gain the most from the therapy:
Try working with a therapist that the surgeon recommends can be helpful as they already have a working relationship.
Keep communication open between the surgeon and team.
Adhere to any precautions and restrictions set by the surgeon and therapy team.
Maintain recommended exercises at home between sessions.
Ease into activity and avoid overexertion.
Post spine surgery physical therapy helps accelerate the healing process and serves to help individuals regain their quality of life.
Body Composition
Power Of Protein
Protein is an essential component of muscle development, bone density, muscle mass, and lean tissue when building a healthy body. Protein is necessary for all the body’s physiological functions.
References
Adogwa, Owoicho et al. “Assessing the effectiveness of routine use of postoperative in-patient physical therapy services.” Journal of spine surgery (Hong Kong) vol. 3,2 (2017): 149-154. doi:10.21037/jss.2017.04.03
Atlas, S J, and R A Deyo. “Evaluating and managing acute low back pain in the primary care setting.” Journal of general internal medicine vol. 16,2 (2001): 120-31. doi:10.1111/j.1525-1497.2001.91141.x
Gellhorn, Alfred Campbell et al. “Management patterns in acute low back pain: the role of physical therapy.” Spine vol. 37,9 (2012): 775-82. doi:10.1097/BRS.0b013e3181d79a09
Jack, Kirsten et al. “Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review.” Manual therapy vol. 15,3 (2010): 220-8. doi:10.1016/j.math.2009.12.004
Lindbäck, Yvonne et al. “PREPARE: Pre-surgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial protocol.” BMC musculoskeletal disorders vol. 17 270. 11 Jul. 2016, doi:10.1186/s12891-016-1126-4
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