Bulging Disc – Causes, Symptoms, Diagnosis, Treatment

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bulging disc (protrusion) occurs when the disc annulus remains intact, but forms an outpouching that can press against the nerves. A true herniated disc (also called a ruptured or slipped disc) occurs when the disc annulus cracks or ruptures, allowing the gel-filled center to squeeze out.

bulging disc refers to when the inner nucleus of a vertebral disc protrudes to it’s outer layer. A disc bulge may happen as a result of a great amount of pressure being placed on the disc, or if the disc has degenerated from age and other factors. Just because a bulge has occurred doesn’t mean there will be any bulging disc symptoms; it is only when it comes in contact with surrounding tissues or nerves that it begins causing problems.

Anatomy of the Lumbar Spine

The vertebral column, also called the backbone, is made up of 33 vertebrae that are separated by spongy disks and classified into four distinct areas. The cervical area consists of seven bony parts in the neck; the thoracic spine consists of 12 bony parts in the back area; the lumbar spine consists of five bony segments in the lower back area; five sacral bones (fused into one bone, the sacrum); and four coccygeal bones (fused into one bone, the coccyx).

Lumbar disk disease occurs in the lumbar area of the spine. The lumbar area of the spine (and other areas of the spine) is made up of two parts, including the following:

  • Vertebral bodies –The parts that are made of bone.
  • Intervertebral disks (also known as the disks) – The disks are located between the bony parts of the spine and act as “shock absorbers” for the spine.

The vertebral bodies are numbered from 1 to 5 in the lumbar spine and the disks are located between two of the vertebral bodies and are numbered accordingly (such as a disk at L2-3, or between the lumbar disks numbered 2 and 3). The intervertebral disk is composed of two parts, including the following:

  • The annulus fibrosis – A tough outer ring of fibrous tissue.
  • Nucleus pulposus – Located inside the annulus fibrosis; a more gelatinous or soft material.

Causes for a Bulging Disc

  • Repetitive trauma – such as poor posture, poor ergonomics, or repetitive heavy work can lead to disc degeneration and a bulging disc. These long term injuries are often also associated with poor muscle strength, obesity, and other factors such as smoking.
  • An Injury caused – by sudden forces or load on the disc such as a car accident or an awkward heavy lift. This sudden increase in pressure on the disc can cause damage and tears to the annulus that causes a bulging disc.
  • Spinal Degeneration – While some degeneration is a normal part of the aging process, poor spinal function and posture will dramatically speed up disc degeneration with a bulging disc.
  • People who have led a sedentary lifestyle or those who smoke – increase the chances for bulging discs.
  • Continuous strain on the disc from injury or heavy lifting – and strain can wear them down throughout the years.
  • Weakened back muscles – can accelerate the process and may lead to a sudden herniation of the weakened disc.
  • Although bulging discs occur over time, herniated discs may occur quickly by trauma.
  • Bad posture – including improper body positioning during sleep, sitting, standing, or exercise are all risk factors that may contribute to the development of a bulging disc.
  • Obesity
  • High contact sports or activities – are also risk factors.
  • Runners who fail to use shoes that provide orthopedic support – may also develop bulging discs.
  • Activities that place stress and strain on the spine – can lead to the weakening of the discs.

Symptoms of Bulging Disc

If a bulging disc has not yet reached the stage of herniation, a patient may have little to no pain involved. A bulging disc may have no pain at all because it has not reached a certain severity level, and this can make it difficult to identify the bulging disc symptoms before the condition becomes more severe.

Most commonly, bulging discs create pressure points on nearby nerves which create a variety of sensations. Evidence of a bulging disc may range from mild tingling and numbness to moderate or severe pain, depending on the severity. In most cases, when a bulging disc has reached this stage it is near or at herniation.

  • Tingling or pain in the fingers, hands, arms, neck or shoulders – This could indicate a bulging disc in the cervical area.
  • Pain in the feet, thighs, lower spine and buttocks – This is the most common symptom and could indicate an issue in the lumbar region.
  • Difficulty walking or feeling of impairment while lifting or holding things.
  • Loss of Bladder or Bowel Function – There are some bulging disc cases where professional care is essential. In some cases, such as when you lose bowel or bladder control, it is deemed an emergency, and you may require immediate surgery. These bulges usually are very significant and affect your nerve control involving your bladder or bowels. You should go straight to your nearest emergency department in these instances.
  • Weakness in your limb muscles – is a significant concern. If you experience arm, hand, leg or foot weakness, please seek prompt medical assessment.
  • The reduced or altered sensation – is your next priority. Mild disc bulges can reduce your ability to feel things touching you, e.g. numbness or pins and needles. If you experience any of the above symptoms, you should seek professional assistance.
  • Referred Pain – Pain in your limbs, e.g. legs (sciatica) or arms (brachialgia) is usually a more significant injury than when experiencing only spinal pain. We recommend that you seek the professional advice of your trusted spinal care practitioner.
  • Spinal Pain – Interestingly, if you are only experiencing spinal pain, bulging discs are generally mild injuries and the most likely to rehabilitate quickly. Please adhere to low disc pressure postures and exercise accordingly. If in doubt, please seek professional advice.
  • Intermittent or continuous back pain. This may be made worse by movement, coughing, sneezing, or standing for long periods of time.
  • Spasm of the back muscles
  • Sciatica. Pain that starts near the back or buttock and travels down the leg to the calf or into the foot.
  • Muscle weakness in the legs
  • Numbness in the leg or foot
  • Decreased reflexes at the knee or ankle
  • Changes in bladder or bowel function

Associate clinical feature is

Approximate area of “saddle anesthesia” seen from behind (yellow highlight)
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These symptoms require immediate medical evaluation as they may be a sign of a potentially life-threatening condition.

Diagnosis of Bulging Disc

Physical Examination

A physical exam for diagnosing disc pain may include one or more of the following tests:

  • Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc.
  • Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a lumbar herniated disc (straight leg raise test).
  • Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by a herniated disc. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
  • Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine.

Lab Test

Imaging

  • X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, or fractures. It’s not possible to diagnose a herniated disc with this test alone.
  • Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with a bulging disc. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression. It can also detect bony overgrowth, spinal cord tumors, or abscesses.
  • A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, a bulging disc in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, spinal cord tumors, and abscesses. A CT scan may follow this test.
  • Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc is damaged.
  • Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc.
  • Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure.

Treatment of Bulging Disc

Non-Surgical

  • Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
  • Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support
  • Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.
  • Hot Bath –  Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.
  • Traction – traction is the best essential treatment for bulging discs, pinched nerve, radiating pain management. It can be done in a manual and dynamic way to relieves pain in bulging discs.
  • Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower back pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • Back school –  is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
  • Patient education – on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
  • Physical therapy – which may include ultrasound, massage, conditioning, and exercise. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury. Physical therapists can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness.
  • Over the Door Traction – This is a very effective treatment for a disc bulge. It helps in relieving muscle spasms and pain. Typically a 5 to 10-pound weight is used and it is important that patients do this under medical guidance.
  • Weight control – By keto diet or maintaining or changing the food habit to reduce the weight not any movement during the time of acute pain.
  • Use of a lumbosacral back support
  • Typically – conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.
  • Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal back pain of all types. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
    • In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
    • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
    • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
    • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.
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Medications

  • Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
  • Muscle Relaxants –  These medications provide relief from spinal muscle spasms.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
  • Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
  • Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
  • NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenacetoricoxib, ibuprofen, and naproxen.
  • Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
  • Dietary supplement – to remove general weakness & improved health.
  • Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
  • Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
  • Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
  • Steroid injections  The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves (Fig. 3). About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with a physical therapy and/or home exercise program.

Surgery

  • Microdiscectomy – for a herniated disc, a minimally-invasive procedure in which the herniated portion of the disc is removed.
  • Artificial disc replacement – for degenerative disc disease and herniated discs is a minimally invasive procedure that replaces a damaged disc with a specialized implant that mimics the normal function of the disc, maintaining mobility.
  • Spinal fusion – fusion for degenerative disc disease, in which the disc space is fused together to remove motion at the spinal segment. Spinal fusion involves setting up a bone graft, as well as possible implanted instruments, to facilitate bone growth across the facet joints. Fusion occurs after the surgery.
  • Open Back Surgery – Traditionally, bulging discs are treated with an open back procedure, meaning the surgeon makes a large incision into the skin and cuts muscle and surrounding tissue to gain access to the problematic disc. This traditional surgical option is invasive, requires overnight hospitalization, general anesthesia, and requires a lengthy recovery coupled with strong pain medication.
  • Endoscopic Surgery – Fortunately, you have a second option with endoscopic spine surgery. Thanks to the advancement of surgical technology at bulged disc surgery can be performed using endoscopic procedures, meaning the surgeon makes a small incision to insert special surgical tools. During an endoscopic bulging disc operation, the surgeon uses a tiny camera to visualize and gain access to your damaged disc. This minimally invasive new approach offers shorter recovery, easier rehabilitation, and a much higher success rate than open back or neck surgery. A local anesthetic is all that is usually required.

Bulging Disc Physiotherapy Treatment

Most minor and moderately bulging disc injuries are treated conservatively without the need for surgery. Torn fibres of the annulus will heal and the disc bulge to usually resolve fully.

  • While this occurs, your bulging disc treatment centres on encouraging the fluid to return and remain in the centre of the disc. This rehabilitation keeps the torn fibres closer to one another and the structure of the annulus as healthy as possible.
  • Your physiotherapist will advise you on the best positions to stay in and may tape or brace your spine. They’ll also explain to you the postures to avoid, which can be detrimental to your recovery.
  • By maintain the disc fluid in the central position that you intend it to stay, you are helping Mother Nature to lay down its scar tissue optimally for an excellent long-term solution. Please remember that scar tissue formation will take at least six weeks, so the longer that you avoid aggravating postures, the better!

PHASE I – Pain Relief & Protection

  • Managing your pain is usually the main reason that you seek treatment for a bulging disc. In truth, it was the final symptom that you developed and should be the first symptom to improve.
  • You are managing your inflammation. Inflammation is the primary short-term reason for why you have suddenly developed bulging disc symptoms. It best reduced via ice therapy and techniques or exercises that unload the inflamed structures.
  • Your physiotherapist will use an array of treatment tools. They aim to reduce your pain and inflammation. These treatment modalities may include ice, electrotherapy, acupuncture, unloading taping techniques, soft tissue massage, gentle exercise and temporary use of a back brace. Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen.
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PHASE II – Bulging Disc Exercises

  • As your pain and inflammation settle, your physiotherapist will turn their attention to restoring your normal joint alignment and range of motion, muscle length and resting tension, muscle strength and endurance.
  • Your physiotherapist will commence you on a lower abdominal and core stability program to facilitate your important muscles that dynamically control and stabilise your spine.
  • Researchers have discovered the importance of your back and abdominal core muscle recruitment patterns. Standard recruitment order of your deeper muscles, then intermediate and finally, superficial muscle firing patterns are typically required to prevent back pain. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you, specific to your needs.
  • Your physiotherapist may recommend a stretching program or a remedial massage to address your tight or shortened muscles. Please ask your physio for their advice.

PHASE III – Restoring Full Function

  • As your back’s dynamic control improves, your physiotherapist will turn their attention to restoring your normal pelvic and spine alignment and its range of motion during more stressful body positions and postures. They’ll also work on your outer core and leg muscle power.
  • Depending on your chosen work, sport or activities of daily living, your physiotherapist will aim to restore your function to allow you to return to your desired activities safely. Everyone has different demands for their body that will determine what specific treatment goals you need to achieve. For some, it is merely to walk around the block. Others may wish to run a marathon.

Your physiotherapist will tailor your back rehabilitation to help you achieve your own functional goals.

PHASE IV – Preventing a Recurrence

  • Back pain does tend to return. The main reason back pain recurs is due to insufficient rehabilitation. In particular, poor compliance with deep abdominal and core muscle exercises. You should continue a version of these exercises routinely a few times per week. Your physiotherapist will assist you in identifying the best activities for you to continue indefinitely.
  • In addition to your muscle control, your physiotherapist will assess your spine and pelvis biomechanics and correct any defects. It may be as simple as providing you with adjacent muscle exercises or some foot orthotics to address any biomechanical faults in the legs or feet.
  • General exercise is a vital component to successfully preventing a recurrence. Your physiotherapist may recommend pilates, yoga, swimming, walking, hydrotherapy or a gym program. These modalities all appear to help back pain. Exercise will assist your back pain relief in the long-term.

Bulging Disc Exercises

You physiotherapist will prescribe the best bulging disc exercises. They will consider your disc bulge location, size, neurological symptoms and the acuteness of your symptoms. Please follow their recommendations as they guide you from back pain and back towards your healthy life.

Fine-tuning and maintenance of your back stability and function are best achieved by addressing any deficits and learning self-management techniques. Your physiotherapist will guide you.

What is Physiotherapy Treatment?

Physiotherapists help people affected by illness, injury, or disability through exercise, manual joint therapy, soft tissue techniques education, and advice.  Physiotherapists maintain physical health, help patients to manage pain, and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.

There is a multitude of different physiotherapy treatment approaches.

Acute & Sub-Acute Injury Management

  • Early Acute Injury Treatment
  • Sub-Acute Soft Tissue Injury Treatment

Hands-On Physiotherapy Techniques

Your physiotherapist’s training includes hands-on physiotherapy techniques such as:

  • Joint Mobilisation (gentle joint gliding techniques)
  • Joint Manipulation
  • Physiotherapy Instrument Mobilisation (PIM)
  • Minimal Energy Techniques (METs)
  • Massage
  • Soft Tissue Techniques

Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.

Physiotherapy Taping

Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.

  • Supportive Strapping
  • Kinesiology Taping

Alternatively, your physiotherapist may recommend a supportive brace.

Acupuncture and Dry Needling

Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.

  • Acupuncture
  • Dry Needling

Physiotherapy Exercises

Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the “best exercises” for you and the most appropriate “exercise dose” for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.

  • Muscle Stretching
  • Core Exercises
  • Strengthening Exercises
  • Neurodynamics
  • Balance Exercises
  • Proprioception Exercises
  • Real-Time Ultrasound Physiotherapy
  • Swiss Ball Exercises

Biomechanical Analysis

Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.

  • Biomechanical Analysis
  • Bike Fit Setup
  • Gait Analysis
  • Video Analysis

Hydrotherapy

Aquatic water exercises are an effective method to provide low bodyweight exercises.

  • Hydrotherapy

Sports Physiotherapy

Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.

  • Sports Injury Management
  • Prehabilitation

Vestibular Physiotherapy

  • BPPV Manoeuvres
  • Vestibular Physiotherapy
  • Falls Prevention

Women’s Health

Women’s Health Physiotherapy is a particular interest group of therapies.

  • Women’s Health Physiotherapy
  • Pelvic Floor Exercises

Workplace Physiotherapy

Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.

  • Home / Office Workstation Setup
  • Corporate Wellness
  • Workplace Wellness

Electrotherapy

  • Electrotherapy & Local Modalities
  • Therapeutic Ultrasound
  • TENS Machines
  • EMS Machines

Plus Much More

Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.

References

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