A pinched nerve in the hip can cause numbness, tingliness, weakness, and pain. A pinched/compressed nerve creates pressure that can result from a bone structural issue like hip misalignment or the nerve getting overly stretched, stuck, twisted, or kinked. The pressure obstructs the neural pathways and decreases neural activity. This causes pain. If discomfort or pain is present, chiropractic, physical rehabilitation, rest, exercise, and ice and heat can release and reset the nerve and help prevent re-injury.
Pinched Nerve In The Hip
A pinched or compressed nerve results from pressure being applied to the nerve. A pinched nerve in the hip often causes pain in the groin region, radiating down the inner thigh to the knee. The pain can feel like a dull ache or a sharp, burning pain. Individuals also report tightness, numbness, or a tingling sensation in the buttocks. The most common causes include:
Unhealthy posture.
Sitting for too long without moving around.
Misaligned bone or cartilage.
Muscle strain.
Pregnancy.
Obesity.
Inflamed tissue.
Herniated disc.
Arthritis.
Bone spurs.
Chiropractic
Different causes require different treatment approaches. For example, an obese individual could require chiropractic adjustments, specific exercises/stretches, and diet adjustments to address the whole body. The recommended treatment plans can vary but usually include:
Physical therapeutic massage.
Manipulative therapies of the joints and muscles.
Mobilization of the joints.
Soft tissue treatments.
Spinal decompression.
Exercise.
Walking and activity can worsen the pain when the hip presents with pain. This can cause the rest of the body to compensate by shifting the weight to the healthy side, which can cause even more pain in the back or legs or cause another injury. Regular chiropractic hip adjustments will improve posture, maintaining muscle and skeleton alignment that will prevent pinching nerves in the hip.
Chiropractic Hip Treatment
References
Ahuja, Vanita, et al. “Chronic hip pain in adults: Current knowledge and future prospective.” Journal of anaesthesiology, clinical pharmacology vol. 36,4 (2020): 450-457. doi:10.4103/joacp.JOACP_170_19
Christmas, Colleen, et al. “How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey.” The Journal of family practice vol. 51,4 (2002): 345-8.
“Free Communications: Case Reports: Hip.” Journal of Athletic Training vol. 38,2 Suppl (2003): S.73–S.74.
Sciatica is experienced as lower back pain and pain that radiates down the back of the legs. It is pain caused by compression, irritation, or inflammation of the sciatic nerve. It is generally experienced on one side of the body. Body movements like twisting, bending, sitting, or responses like coughing and sneezing can worsen the pain. Individuals with sciatica also experience muscle weakness, numbness, tingling, or electrical shock-like sensations. Injury Medical Chiropractic and Functional Medicine Clinic offer manual and motorized sciatic nerve decompression to stretch/realign the spine, release the compressed nerves, and relieve pain.
Sciatic Nerve Decompression
The spine consists of 23 spinal discs that are shock absorbers for the body during movement. Each disc consists of a soft inner core of a gel substance and a thick outer layer. Wear and tear of the spinal discs from aging, degenerative disc disease, repetitive physical activities like lifting and bending, obesity, and poor posture are some of the factors that can stress the spine, causing the thick outer layer of the spinal disc to crack/breakdown causing the soft inner core to leak out forming a bulging or herniated disc. This type of injury compresses, pinches, or irritates one or more nerve roots that form the sciatic nerve, triggering sciatica.
Spinal stenosis or the narrowing of the spinal canal.
Spondylolisthesis, or the slipping or dislocation of the spinal vertebrae in the lower part of the spine.
Are also known sciatica causes.
Symptoms
Common compressed nerve symptoms include:
Pain or burning sensations radiating down the leg.
Because branches of the sciatic nerve extend from the lumbar spine through the buttocks and down the leg, pain, burning sensations or dull aching can present along the nerve’s pathway if the nerve gets compressed or irritated.
Weakness in the affected leg.
When walking or moving the legs, the nerves transmit information to the brain, stimulating the muscles to react in specific ways.
A pinched sciatic nerve can cause interference with relaying signals, resulting in weakness.
Numbness.
The compression impedes blood circulation and nerve energy transmission.
Spinal decompression therapy relieves pressure on the spine by pulling/stretching it in small increments. Non-surgical spinal decompression creates negative pressure within the discs. The negative pressure pulls or vacuums back the disc material that has protruded or herniated and an abundance of nutrients to activate the healing response. The chiropractor, physical therapist, or nurse uses motorized medical equipment with sensors linked to a computer-aided system to perform the procedure. The equipment is designed to adjust the pull force accordingly to prevent muscle resistance. The adjustable table also allows the spine to be stretched at different angles to target the upper or lower back.
The objective of spinal decompression treatment is to relieve the symptoms of sciatica or disc disorders and heal the injured disc. We utilize spinal decompression as an effective tool in treating a vast array of spinal conditions.
DRX9000 Non-Surgical Spinal Decompression
References
Berry, James A et al. “A Review of Lumbar Radiculopathy, Diagnosis, and Treatment.” Cureus vol. 11,10 e5934. 17 Oct. 2019, doi:10.7759/cureus.5934
Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2022 Feb 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK507908/
Giuffre BA, Jeanmonod R. Anatomy, Sciatic Nerve. [Updated 2021 Jul 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK482431/
A pinched nerve may not feel like it is healing. This is because of the soreness, aches, discomfort, and tingling feelings/sensations around the affected area. This could be the neck, shoulder, arm, hands, back, legs, and feet. However, when the achiness and tingling move around and shift, it is a sign of the pinched nerve healing.
Amount of Time For Pinched Nerve Healing
Waiting for the nerve to heal is not a recommended treatment option, as most pinched nerves do not fully recover on their own. A pinched nerve usually takes around six weeks to heal with proper treatment. The longer the nerve stays pinched, the more likely there will be permanent damage. To keep the pinched nerve from returning and getting worse, individuals are recommended to incorporate a pre-habilitation plan that involves continuing rehabilitation exercises to strengthen and keep the muscles, ligaments, and nerves loose, and adjusting posture, work, exercise, and diet habits to prevent re-injuring the nerve or cause new injury/s.
Common Nerve Sites
Nerves run throughout the body, so it’s possible to experience a pinched nerve anywhere. The most common pinched nerve sites occur at joints where there is constant movement. These areas include:
Neck
Shoulders
Lower Back
Arms
Hands
Feet
Healing Signs
Individuals often believe that their pinched nerve is getting worse because of soreness, aches and pains, and weird sensations. When the pain stays in one area, that could be a sign that the nerve has not been fully stretched/released and/or that there is still compression taking place. Treatment and healing include feeling the symptoms but in a different way. The symptoms will move up, down, or around depending on where the pinched nerve is. Treatment takes the nerve/s and stretches/elongates them, but the pinch created a nerve crimp, crease, fold that wants to return to the pinched position. This is why continued treatment and stretching are recommended, as a spasm, trauma, or some awkward movement can cause the nerve to re-fold to the pinched position or cause a whole new pinch.
Chiropractic Release
Chiropractic treats pinched/compressed nerves with several therapeutic modalities. These include:
Body Adjustments
Flexion-distraction
Therapeutic massage
Traction
Inversion
Laser therapy
Ultrasound
Combined, these methods can help heal pinched nerves and keep them from recurring.
Body Composition
Skeletal Muscle
Skeletal muscle is a major muscle group. These muscles are attached to the bone by the tendons. Skeletal muscles incorporate nerves, blood vessels, and connective tissue to operate as a unit. Each skeletal muscle consists of cells that come together that form bundles of skeletal muscle fibers.
Strength training stimulates the muscle fibers. When combined with proper nutrition causes hypertrophy/muscle growth.
Muscles contract and shorten to pull bones and joints, allowing body movement.
The nervous system signals the nerves in the muscle/s and triggers these contractions.
Skeletal muscle helps the body:
Maintain posture
Generate body heat
Stability to the bones and joints
References
Bowley, Michael P, and Christopher T Doughty. “Entrapment Neuropathies of the Lower Extremity.” The Medical clinics of North America vol. 103,2 (2019): 371-382. doi:10.1016/j.mcna.2018.10.013
Campbell, W. “Diagnosis and management of common compression and entrapment neuropathies.” Neurologic clinics vol. 15,3 (1997): 549-67. doi:10.1016/s0733-8619(05)70333-9
England, J D. “Entrapment neuropathies.” Current opinion in neurology vol. 12,5 (1999): 597-602. doi:10.1097/00019052-199910000-00014
Kane, Patrick M et al. “Double Crush Syndrome.” The Journal of the American Academy of Orthopaedic Surgeons vol. 23,9 (2015): 558-62. doi:10.5435/JAAOS-D-14-00176
Most if not all of us have probably used heat and/or ice on a sprain, strain, or sore area of the body. Having a pinched nerve, however, has a different feeling than a sprain or strain. Chiropractic treatment for a pinched nerve is recommended, but if the pain isn’t too bad, then home care can work. Which is better for a pinched nerve, heat or ice? Both. Using heat and ice helps reduce swelling, increases blood flow to the area, and relaxes the muscles around the pinched nerve. The objective is to know when to use ice and/or heat.
Applying Heat on a Pinched Nerve
Applying heat on a pinched nerve is fine. The general guideline for a pinched nerve is to use heat only after the pain has subsided/reduced.
When pain presents or flares up, use ice before using heat.
Do not apply heat to the area directly after applying ice.
Wait 30 minutes to an hour.
Keep the heat on the affected area for 10 to 20 minutes at a time.
Take a minimum 30-minute break between sessions.
If the heat helps, make the heat moderate and use it on the area for an hour or more.
Extended heat therapy is beneficial for severe pain from a pinched nerve.
The equivalent is like soaking in a hot bath.
Heat for a Pinched Nerve Benefits
Heat soothes and relaxes both the muscles and the mind.
Heat increases healing abilities by circulating new blood to the injured/affected area, helping to flush toxins away.
Decreases tension and spasms in the muscles.
Increases the range of motion in the joints.
When Not To Use Heat Therapy
It can be dangerous for individuals with pre-existing conditions. Conditions include:
If home remedies don’t work, know when to consult a chiropractor.
Doctors of chiropractic specialize in pinched/compressed nerves. A chiropractor is trained in different techniques to relieve the pressure and release the nerve back to its proper position.
Body Composition
Peripheral Artery Disease
Peripheral artery disease or PAD is the narrowing of the arteries that carry blood away from the heart to the other areas of the body. What to know about PAD:
Peripheral artery disease risks increase with age.
Over half of affected individuals do not present with symptoms.
Around one-fourth of individuals with peripheral artery disease have diabetes mellitus.
Smokers have an increased risk of developing PAD.
This is why it’s important to monitor blood pressure.
References
Chandler, Anne, et al. “Using heat therapy for pain management. (clinical practice).” Nursing Standard, vol. 17, no. 9, 13 Nov. 2002, pp. 40+. Accessed 15 Sept. 2021.
Edzard Ernst, Veronika Fialka, Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy, Journal of Pain and Symptom Management, Volume 9, Issue 1, 1994, Pages 56-59, ISSN 0885-3924, doi.org/10.1016/0885-3924(94)90150-3.
Shu, Jun, and Gaetano Santulli. “Update on peripheral artery disease: Epidemiology and evidence-based facts.” Atherosclerosis vol. 275 (2018): 379-381. doi:10.1016/j.atherosclerosis.2018.05.033
The hamstring muscles are three muscles in the back of the thigh. The sciatic nerve goes through or around and down the legs into the feet. Hamstring syndrome is a condition where injury or spasm apply pressure compressing the sciatic nerve.
The nerve can become pinched between the hamstring muscles and the pelvic bone or the band of tissue that connects the hamstring muscles.
This can cause discomfort, tingling, numbness, and pain down the back of the leg, hip, buttock, and into the foot.
Pain can present when sitting down or stretching the hamstrings.
Pain reduces when lying flat on the back.
Hamstring syndrome
This condition could be the result of wearing and tearing to the back muscles and hamstring muscles. It is often seen in individuals that play sports involving running, kicking, and/or jumping. But it can happen to anyone from some awkward leg motion causing the muscles to spasm that can twist around the sciatic nerve or pull on it, causing various symptoms. A doctor or chiropractor will diagnose the condition by examining the symptoms, physical activities, and leg. Most individuals diagnosed with hamstring syndrome report discomfort or pain where they sit down. The pain gradually worsens when performing physical activities, regularly sitting, and when flexing the knee. Hamstring syndrome usually gets better within a few weeks with proper rest and home care. A doctor or chiropractor will recommend exercises and stretches to strengthen the muscles.
Home care
Ask the doctor or chiropractor about taking over-the-counter pain medication:
Acetaminophen – Tylenol
Ibuprofen – Advil, Motrin
Naproxen – Aleve
Read and follow all label instructions.
Use an ice pack on the pain area for 10 to 20 minutes at a time.
Try to do this every 1 to 2 hours for 3 days or until the swelling goes down.
After 2 or 3 days, if the swelling is gone, apply heat.
Use a warm water bottle, heating pad, or warm cloth over the area.
Avoid sitting if possible, unless it feels better than standing.
Take short walks to keep the muscles stretched.
Don’t do anything that causes symptoms to worsen.
Return to normal physical activities slowly.
If symptoms do not improve, then contact a doctor or chiropractor.
Caffeine falls under stimulants, or substances that excite the systems throughout the body.
Ingesting caffeine can cause the body to experience increased excitement, especially in the cardiovascular system.
This excitement causes the heart rate and blood pressure to rise
Then it lowers back down to baseline levels for most healthy individuals.
It is recommended to drink coffee in moderation, safe for individuals with pre-existing cardiovascular conditions.
References
de Ridder, Roel et al. “Neurodynamic sliders promote flexibility in tight hamstring syndrome.” European journal of sports science vol. 20,7 (2020): 973-980. doi:10.1080/17461391.2019.1675770
Matsuda, Dean K. “Editorial Commentary: Proximal Hamstring Syndrome: Another Pain in the Buttock.” Arthroscopy: the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association vol. 34,1 (2018): 122-125. doi:10.1016/j.arthro.2017.08.260
Park, Jung Wee et al. “Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain.” The bone & joint journal vol. 102-B,5 (2020): 556-567. doi:10.1302/0301-620X.102B5.BJJ-2019-1212.R1
Individuals experiencing radiculopathy in and around the neck notice it immediately often driving them to the medicine cabinet. This condition presents with:
Acute pain
Numbness
Muscle spasms
However, medication will only help relieve the pain temporarily but it won’t alleviate what is causing the radiculopathy. This is because pain medication/s can exacerbate the condition by blocking the pain signals with the root nerve issue never being resolved. Chiropractic is a complete solution that specifically mobilizes the cervical joints where nerve impingement is happening. The objective is to help individuals understand the underlying cause of the acute pain induced by radiculopathy and provide long-term pain relief through cervical joint mobilization.
Radiculopathy Pain
To determine what cervical nerve bundles are being affected by a subluxation or vertebral compression a chiropractor needs to isolate the pain. This is accomplished through a description of symptoms, radiological imaging to provide visual confirmation, and an examination of the affected area. Isolating the pain allows the chiropractor to determine the extent of misalignment and how much the nerve is being compressed. This will help in the development of a customized treatment plan. A chiropractor will be able to see and feel the degree of pressure being placed on the nerve or bundle of nerves.
Mobilizing The Cervical Joints
Chiropractors approach this directly based on the individual and the severity of the case. The most common joint mobilizations include:
Low-impact adjusting will shift the misaligned vertebrae back into place
Adjustments to the opposite non-painful area will help counterbalance stress in the spine
Radiculopathy improvement consists of:
The cervical spine is stabilized through bracing and posture supports
Isometric exercises will recondition the neck, shoulders, and upper back
Range of motion exercises will prevent any subtle compression/s
Corrective restoration of the cervical spine’s curve
The spine returns to normal during cervical joint mobilization and alleviates radiculopathy immediately and long term.
Proper chiropractic care will correct the affected nerve bundle, and stabilize the cervical spine to prevent/resist:
Compression
Translation
Subluxation
Other shifts that can occur
Chiropractic Mobilization Long Term Relief
A pinched nerve should not be treated with over-the-counter medications for long-term health. Corrective chiropractic mobilization is a recommended course of action for alleviating this and other musculoskeletal conditions. Chiropractic understands the nature and severity of radiculopathy as well as developing the proper customized treatment plan that will bring optimal results.
Body Composition
DASH Diet Example
Breakfast
3/4 cup bran flakes cereal with 1 banana and 1 cup low-fat milk
1 slice whole-wheat bread with 1 tsp. unsalted butter
1 orange
1 cup coffee
Lunch
Sandwich 2 slices of whole-wheat bread
3 oz. grilled thin chicken breast
2 slices low-fat cheese
1 tbsp. mustard
Salad
1/2 cup chopped/diced cucumbers
1/2 cup chopped/diced tomatoes
1 tablespoon sunflower seeds
1 teaspoon low-calorie non-cream dressing
1/2 cup fruit cocktail with no sugar
Snack
1/3 cup unsalted almonds
Dinner
3 oz. lean beef with 2 tbsp. fat-free, low sodium gravy
The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the musculoskeletal system’s injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.
Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, CTG*
email: coach@elpasofunctionalmedicine.com
phone: 915-850-0900
Licensed in Texas & New Mexico
Open Orthop J. 2016. A Qualitative Description of Chronic Neck Pain has Implications for Outcome Assessment and Classification. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5301418/
Evid Based Complement Alternat Med. 2015. Complementary and Alternative Medicine for the Management of Cervical Radiculopathy: An Overview of Systematic Reviews. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4541004/
Pinched nerves occur when added pressure is applied to a nerve or set of nerves from surrounding tissues like bones, cartilage, muscles, or tendons. The pressure affects the nerve’s ability to function properly and usually causes pain, tingling, numbness, or weakness. A pinched nerve can occur at various sites in the body. Whether located in the neck, shoulder, arm, hand, back, or knees, they can lead to other debilitating conditions/injuries and permanent nerve damage if left untreated.
Pinched Nerves
The nerves are not actually being pinched but are being compressed. The added pressure on or around the nerve causes painful sensations that can also include:
Pinched nerves are nothing to dismiss. Individuals experiencing any of the above symptoms should get a proper diagnosis from a chiropractor.
Compression Goes Away By Itself
A compressed nerve can go away on its own if the pain has recently started or is not severe. In addition, home remedies like rest, heat, ice, and stretching can be utilized to help the compression subside on its own.
Length of Time It Takes for a Pinched Nerve to Heal
The length of time depends on the reason why the nerve is compressed and irritated. For example, some pinched nerves are brought on from poor posture and tight muscles. These can usually heal within 4 weeks. However, if the pain has been going on for some time, like more than 3 months, it will take longer, especially to identify the root cause/s and address them according to their severity.
Treatment Options
Chiropractic Adjustments and Massage
These two types of treatment/therapy highly complement each other. A chiropractor understands the importance of massage when it comes to healing and stress relief. Some cases of pinched nerves come from tight muscles and muscle spasms. Along with chiropractic adjustments, massage therapy is perfect for releasing and stretching the nerves back to their natural form.
Studies show that chiropractic massage therapy offers pain relief and also helps reduce any depression and anxiety that the pain symptoms can generate. In addition, comprehensive chiropractic treatment has been proven to be the best and fastest way to deal with pinched nerves.
Get More Sleep
Whenever the body is going through stress and needs repair, more sleep gives the body the time to heal itself. An extra hour of sleep also ensures that the injured area moves less. However, try to avoid sleeping on the stomach and make sure that the pillows being used provide plenty of support.
Warm/Hot Soothing Bath
Ice can really help lower swelling and inflammation, but if icing the area has not relieved the pain after 72 hours, it is time for a warm/hot bath. Warm water increases blood circulation, which delivers oxygen and nutrients to help heal and restore. In addition, heat relaxes the muscles of the body, which relieves pressure on the affected area.
Collagen Nerve Joint Repair
Collagen adds cushion to the spaces between the joints and bones while damaged tissues are being repaired. Collagen is the most plentiful natural protein in the human body. Supplements with glucosamine, chondroitin and hyaluronic acid can help and consume bone broth, a healthy collagen source. An anti-inflammatory diet can also help. Inflammation contributes to pain symptoms. Lowering inflammation lowers pain as well.
Proper Posture
Slouching and poor posture, whether sitting or standing, place added pressure/stress on the joints. When this goes on for long periods or when something traumatic occurs, a pinched nerve can result. A chiropractor will restore the body’s natural curvature. In addition, a chiropractor will discuss and show what proper posture should be and how to strengthen the core to maintain proper posture.
Other Treatment Options
Conventional treatments usually include:
Over the counter pain relievers
Prescription pain relievers for severe cases
Corticosteroids
Microdiscectomy spinal surgery
Regular surgery
Most individuals want to avoid any of the above treatment options. The body has a tremendous ability to heal itself. Chiropractic will reduce the amount of time that is required to heal a pinched nerve. It’s about treating the entire body, not just the symptoms. A customized treatment/recovery diet plan will be developed according to each individual’s needs. At Injury Medical Chiropractic and Functional Medicine Clinic, we encourage anyone experiencing any pain to call us right away.
Composition of the Body
What happens to the body when you stop eating
Not eating for a few hours causes glucose levels in the blood to drop, and insulin release stops. Alpha cells in the pancreas produce a hormone called glucagon that helps the liver break down the body’s stored glycogen, converting it back into glucose. The liver can also produce glucose by utilizing fats, amino acids, and waste.
If the body’s blood sugar levels drop, too low a condition called hypoglycemia happens. It occurs a few hours after eating when there is too much insulin in the blood or certain medications. This is why an individual might feel dizzy, shaky, anxious, or irritable when they have not eaten for several hours. Eating at least 15 to 20 grams of carbohydrates will reverse the symptoms.
Dr. Alex Jimenez’s Blog Post Disclaimer
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that directly or indirectly support our clinical scope of practice.*
Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
References
Dubinsky RM, Miyasaki J.Assessment: Efficacy of transcutaneous electric nerve stimulation in treating pain in neurologic disorders (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.Neurology. 2010;74:173-176.
Shrier I. Does stretching help prevent injuries? Evidence-based Sports Medicine. Williston, VT: BMJ Books; 2002.
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