Following early examinations to measure disc expansions in vitro 10,19, Nachemson 12 proved that the disc was hydrostatic by measuring pressures while rotating a needle in the three principal directions of load. It was concluded that potential for porcine disc injury may exist at low pressures for and the rupture could occur within intradiscal physiological pressures. The procedure is performed under local anesthesia using a flexible catheter into the disc under fluoroscopic guidance. The tests were performed using a hydraulic cylinder that inflates the discs. No difference noted when walking slowly or quickly, or between walking barefoot or with tennis shoes. ... Procedure aimed to remove excess material to reduce intradiscal pressure to relieve the internal disc nociceptors or spinal nerve roots. In a healthy normal state, the NP is, thus, pressurized because the expansion of the volume is restricted by the surrounding AF lamellae and end plates. CORRECT SLEEPING POSTURE 13 ... LUMBAR DISC PROLAPSE DEFINITION It is condition in which there is outpouching of the disc Nucleus pulposus along with few annular fibres and end plate cartilage through the tears in annulus fibrosus into the extradural space. McNally et al. The pressurized disc provides the normal intervertebral spacing and smooth motion of the spine and allows balanced load transfer among the adjacent vertebral bodies. … Similarly, Buser et al. Gradual changes in the pressure might provide biomechanical evidence of biochemical changes in the disc during degeneration or regeneration. the pressure required to separate a gel's disperse phase, the protein-. It is used as a treatment for an illness or medical condition, especially when prescribed or chosen rather than resulting from severe prostration or imminent death. Sitting, bending forward, coughing and sneezing can increase low back discogenic pain. Similarly, Buser et al. also performed in vivo experiments using a similar technology.7 Confirming the findings of McNally and Adams, they reported that normal healthy discs yielded an isotropic pressure profile evidenced by similar pressures in axial and transverse directions. The intervertebral disc is composed of a central gel-like nucleus pulposus (NP) and surrounding anulus fibrosus (AF) with a unique lamellar structure. nucleus. Simulation of previous swelling increased the pressure in standing by 34–43% along the lumbar levels. Pollintine et al. From Nachemsons studies it was assumed that sitting increases the pressure in the nucleus pulposus approximately 40% when compared with standing. Similarly, the loading profile of the end plates lost its homogeneity in healthy normal specimens and shifted toward the perimeter. The loss of water content in the disc due to degeneration translates into the loss of disc height of the intervertebral space, because the NP becomes more compressible and the anular layers lose their ability to withstand axial compressive loading. As the technology develops and measurement of the intradiscal pressure becomes easier, safer, and more reliable, it might be an adjunct evaluation technique to MRI in delineating symptomatic degenerated discs. Intradiscal pressure. springer. Intradiscal pressure measurement was performed by connecting a cannula inserted into the patient's L4-L5 disc space to a pressure transducer. 3 In 1965, Nachemson observed that the pressure in the AF and NP were different and that disc degeneration could alter the pressure. Save my name, email, and website in this browser for the next time I comment. They also confirmed that the degeneration of the disc was associated with anisotropy of pressure within the disc. Sitting, bending forward, … Sato et al. The researchers studied various increasing levels of compression. Thirty-six functional units from 8 porcine spines (S1: T7-T8, S2: T9-T10, S3: T12-T11, S4: T14-T13, S5: L1-L2 and S6: L3-L4) have … The headaches attack just before the storm front and, strangely enough, subside when the barometer rises again. measured the intradiscal pressure profiles in normal and degenerated cadaveric spines loaded axially or in flexion. In sitting, fluctuations in pressure occurred with change in posture and support. Also consciously straightening the back while sitting can increase pressure by 10% compared to sitting in relaxed sitting. KEYWORDS: Intervertebral disc, intradiscal pressure, height disc variation 1 INTRODUCTION The structure of the IVD is both complex and inhomogeneous, allowing successful load-bearing … During the flexion that occurs with sitting, intradiscal pressure is greatest and the disc exerts pressure on the thinnest, least supported area of the supporting ligament known as the annulus fibrosus. This was in contrast to degenerated discs, in which axial and transverse pressures were found to differ. Results: The following values and more were measured: lying prone, 0.1 MPa; lying laterally, 0.12 MPa; relaxed standing, 0.5 MPa; standing flexed forward, 1.1 MPa; sitting unsupported, 0.46 MPa; sitting with maximum flexion, 0.83 MPa; nonchalant sitting, 0.3 MPa; and lifting a 20-kg weight with round flexed back, 2.3 MPa; with flexed knees, 1.7 MPa; and close to the body, 1.1 MPa. Notwithstanding the limitations related to the single-subject design of this study, these differences may be explained by the different transducers used. Medications Utilized In Physical Medicine and Pain Management, Total RVU and work RVU for PM&R and Pain Management Clinics in 2014, CPT Codes for Physical Medicine and Interventional Pain Management, VIDEO: Knee Injection Under Fluoroscopic Guidance, VIDEO: Subacromial Bursa Injection under fluoroscopy, VIDEOS: Lumbar Facet Injections under Fluoroscopy, Bertolotti’s syndrome – Atypical Cause of Low Back Pain, Testosterone Deficiency In Chronic Pain Patients Taking Opioids, Piriformis Muscle Injection With Fluoroscopy. You have entered an incorrect email address! RELATION OF INTRADISCAL PRESSURE AND POSTURE 12. To assess the reliability of intradiscal pressure measurement during in vitro biomechanical testing. 1964;46:1077-92. He was a 45 year old male weighing 70 kg (154-lbs), standing 1.68 m (5’5″), in good physical condition and no history of back pain. The objective of the present work is to determine the internal pressure that promotes the porcine disc disruption. This gradually changes the load transfer patterns in the dorsal and ventral spine and end plates. Home Menu Toggle. Intradiscal Pressure. Lying supine had the lowest disc pressure, flexing forward while standing or sitting substantially increased pressure, this study found no change in pressure when lying supine or laterally, ICD-9 Codes for Physical Medicine and Pain Management, ICD-10 Codes for Physical Medicine and Pain Management, Total RVU and work RVU in Pain Management and PM&R Clinics for 2014, Cervical Interlaminar Epidural With Contralateral Oblique View, Distal Interphalangeal (DIP) Joint Injection, Glenohumeral Joint Injection With Fluoroscopy, First Metatarsophalangeal Joint Injection, Prepatellar Bursa Aspiration and Injection, Lumbar Facet Injections under Fluoroscopy, Hip Intraarticular Steroid Injection Under Fluoroscopy, Knee Injection Under Fluoroscopic Guidance, Glenohumeral Shoulder Intraarticular Steroid Injection Under Fluoroscopy, Subacromial Bursa Injection under fluoroscopy, Understanding an MRI of the Normal Cervical Spine, Understanding the MRI of Cervical Nerve Compression, Understanding the MRI of Cervical Stenosis with Spinal Cord Injury, Understanding an MRI of the Normal Thoracic Spine, Understanding an MRI of the Normal Lumbar Spine, Understanding the MRI of a Lumbar Herniated Disc, Understanding the MRI of Lumbar Degenerative Spondylolisthesis and Spinal Stenosis, Auto-Resorption of Lumbar Disc Herniation, Diffuse Idiopathic Skeletal Hyperostosis (DISH), Vertebral Compression Fracture – MRI Images, Painless Injections – Taking The Sting Out, Definitions Related to the Use of Opioids in Pain Medicine, Topical Compounding Creams Used In Pain Management, The History of Corticosteroids (Glucocorticoids), Diagnostic Test Workups in Pain Management. Dong-gyu Shin. Traction today, also known as “spinal decompression therapy”, addresses the functional and mechanical aspects of discogenic pain and has been used by physiotherapists for years. They confirmed histologic findings of new nucleus formation with recovery in the disc pressure. Patients who have never had low back pain (primar… Abstract. A systematic literature review was conducted, and the results evaluated for the presence of clinical correlation, as well as the type of imaging method used. Methods: Under sterile surgical conditions, a pressure transducer with a diameter of 1.5 mm was implanted in the nucleus pulposus of a nondegenerated L4-L5 disc of a male volunteer 45-years-old and weighing 70 kg. -- Bertolotti's syndrome is an atypical cause of axial low back pain or buttock pain caused by a transitional lumbar vertebrae with a large transverse process that either fuses with the sacrum (sacral ala) or ilium, or forms a pseudoarticulation at that location. Hyung-seok Kim. Nachemson and Morris were the first to assess intradiscal pressure. However this is a common definition, the intensity and content of back schools differ. en.wiktionary.2016 [adjective] Within a disc. in 1999. Intradiscal electrothermal therapy (IDET) is a minimally invasive technique for the treatment of low back pain caused due to problems with the spinal disc. In contrast, degenerated discs demonstrated an irregular stress distribution across the disc. They showed that denucleation of the ventral spinal column unit caused increased instability, confirmed by an increased range of motion and a larger neutral zone. Discography, a procedure in which a contrast agent is delivered into the disc through a needle to increase the pressure within the disc, is a widely used method to manually provoke pain in suspect discs. Objectives. In particular, the variability of measurements will be assessed for repeated measures by considering the effect of specimens and of freezing/thawing cycles. Recently, a group of investigators tested the hypothesis that discography-related pressure could be an indication of disc degeneration and a quantitative marker for the painful disc. Hans–Joachim et al (1999) wanted to reanalyze the original findings of ground breaking research conducted by Nachemson during the 1960’s. Measurement of intradiscal pressure is instrumental in explaining, from a mechanical point, the occurrence of posterior ruptures in the lumbar discs, and provides a basis for the rational treatment of patients with low-back pain in so far as these exhibit increase of pain on increased mechanical loads. The highest pressure range was found during lifting and carrying a case of bottled beverage with a weight of 19.8 kg with bending over and legs straight. New In Vivo Measurements of Pressures in the Intervertebral Disc in Daily Life, SPINE Volume 24, Number 8, pp 755–762 [intra- + G. krinō, to separate, secrete] During the night, pressure increased from 0.1 to 0.24 MPa. Before the computer technology was available, and even now, we will occasionally do this manually. In standing position without previous rest, the IDP was 0.22 MPa at L3/L4 and L4/L5, while it was 0.28 MPa in the lumbosacral disk (Figure 7). Are EMG Findings Related to Epidural Steroid Injection Relief? investigated the relationship of intradiscal pressure coupled with the degeneration and motion. The waist is situated a little higher than the knees and leaning with a straight back against the backrest. In their study, they showed that fibrin inhibited the encroachment of the anulus and facilitated proteoglycan redevelopment. They also collected pressure measurements in both axial and transverse directions by simply rotating the needle during placement in the disc. Since then, technology has changed, but no new studies have been performed. Introduction to Assessments Full-text version of the study can be found for free online here http://www.fonar.com/pdf/spine_vol_24.No.8.pdf. the intradiscal pressure and facet contact force at were C4/5 remarkably increased and unevenly distributed among the unfused segments. It’s also important his worksheet is situated at a correct height; Shelf packer-the intradiscal pressure by lifting a box taught see graph R you can see the intradiscal pressure by two types of lifting. In addition, bending and weight lifting increases the intradiscal pressure. The NP is capable of attracting water molecules and expands its volume through swelling. The lower the subject slouched in the chair, the more the pressure decreased (to a minimum of 0.27 MPa). Due to the inability to access a middle disc in one subject, two discs from the lower region were measured. Early efforts of measurement of disc pressure began in the 1960s. Intradiscal Pressure in the Normal and Degenerated Discs. Typically, discogenic pain is associated with activities that increase the pressure within the intervertebral disc (called intradiscal pressure). The loss of disc height results in the decrease of the gap in the facet joint and subsequent changes in the facet loads. Discogenic lumbar pain (DLP) is a separate entity in the differential diagnosis of low back pain. [ Links ] 37. The effect of the disc degeneration on the segmented spinal motion, especially the neutral zone, was discussed in an earlier chapter. PGY4 - Marianjoy Rehabilitation Hospital, Wheaton, IL. Each layer of the AF is composed of mainly type I collagen,1 in which the collagen fibers are organized in an oblique direction that alters at sequential layers. ABSTRACT. Bed rest is a medical treatment involving a period of consistent (day and night) recumbence in bed. measured the intradiscal pressure profiles in normal and degenerated cadaveric spines loaded axially or in flexion.9,10 They demonstrated that the percentage of load transferred via the dorsal spine increased with disc degeneration. Measurements of intradiscal pressures provide the most direct method of measuring loads on the lumbar spine. Which MRI Finding Predicts Benefit From Cervical Epidural Steroid Injections? Anterior Interosseous Nerve and the “A-OK” muscles, Multifidus Atrophy After Lumbar Radiofrequency Neurotomy, http://www.fonar.com/pdf/spine_vol_24.No.8.pdf, Low-Dose Naltrexone For The Treatment of Fibromyalgia Pain. Lying supine was measured to be 0.10 MPa and lying supine with knees slightly flexed was the lowest recorded value of 0.09 MPa. By Chris Faubel, M.D. This stress profile and deformation pattern, in contrast to healthy normal disc where anular layers are compacted and able to withstand axial loading, sets the stage for anular tear and clefts. -- MRIs one year apart showing resorption of a large lumbar disc herniation. Nachemson and Morris were the first to assess intradiscal pressure. Progressive spinal degeneration with age is also thought to be a major contributor. Lying supine had the lowest disc pressure in both studies while flexing forward while standing or sitting substantially increased pressure in both studies. A 1981 study of the relationship between sinking barometric pressure and migraine/cluster headaches concluded that sinking pressure and headache are interrelated. Gradual changes in the pressure might provide biomechanical evidence of biochemical changes in the disc during degeneration or regeneration. intradiscal Definitions. By measurement of intradiscal pressure in vitro, the hydrostatic properties of the nucleus pulposus of normal lumbar intervertebral disc was established.The stress distribution within normal discs subjected to vertical load was also explained, demonstrating the high tangential strains occurring in the posterior part of the annulus fibrosus. It’s by the principal of the lever. One major difference was that the pressure was found to be lower when sitting in a relaxed position than in relaxed standing. A back schoolis an intervention protocol consisting of an educational program and skills acquisition program, including physical exercises. Each layer of the AF is composed of mainly type I collagen. The hypothesis that rigid fusion has a significant effect on intersegmental mobility and the increase in intradiscal pressure in the upper adjacent segment could not … In vivo measurements of intradiscal pressure discometry, a method for the determination of pressure in the lower lumbar discs. As a result, the disk can herniate. It can be cautiously concluded that the intradiscal pressure during sitting may in fact be less than that in erect standing, that muscle activity increases pressure, that constantly changing position is important to promote flow of fluid (nutrition) to the disc, and that many of the physiotherapy methods studied are valid, but a number of them should be re-evaluated. Definition. intradiscal pressure to complement earlier data from Nachemson with dynamic and long-term measurements over a broad range of activities. As shown in the aforementioned stress profilometry experiments, the AF in the degenerated discs is associated with increased stress levels and localized stress concentrations. Department of Orthopedic Research and Biomechanics, Ulm, Germany Biomechanical changes consisting of increased intradiscal pressure, increased facet loading, and increased mobility occur after fusion and have been implicated in causing adjacent segment disease. They demonstrated similar pressure levels to those shown by Nachemson.5. Their central location in the nucleus pulposus was controlled under fluoroscopy in anterior-posterior (a.p.) springer. investigated the relationship of intradiscal pressure coupled with the degeneration and motion.11 They looked at the pressure changes in the intervertebral disc under axial compression as they gradually removed the nucleus via a vacuum tissue removal system. It has been shown that the disc is a highly viscoelastic fluid-like material with limited compressibility.2 The water content and, therefore, the intradiscal pressure, are critical for maintenance of normal motion of the spinal segments and for avoiding neurologic complications. Relaxed sitting on a stool with normal straight back produced a pressure of between 0.45 MPa to 0.50 MPa. However, fusion can increase intradiscal pressure and other stress at adjacent unfused levels, thereby accelerating postsurgical spinal degeneration 8). Recently, a group of investigators tested the hypothesis that discography-related pressure could be an indication of disc degeneration and a quantitative marker for the painful disc.12 Unlike previous studies seeking the minimum discography pressure that provokes pain, they collected the opening pressure, the pressure required to inject contrast agent into the disc, and compared it with the MRI signal—which is an indicator of degeneration. The possibility of obtaining the goals of anterior cervical decompression and fusion while maintaining adjacent segment motion led … Systematic review of the literature on the evaluation of images of degenerative changes of the spine and its clinical correlation. Than the 0.15 MPa caused by laughing while lying laterally mainly type I collagen facet! Flexible catheter into the patient 's L4-L5 disc space to a pressure peak region of 0.45 to 0.50 MPa fibrin. Schools differ this is spontaneous resorption of the end plates lost its homogeneity in healthy normal specimens and of cycles. A broad range of activities Issue: 2 Pages: 313-320 NP is capable attracting. Low back discogenic pain be 0.10 MPa and lying supine was measured be... Storm front and, strangely enough, subside when the anular layers are compressed axial... Pressure measurements in both studies straightening the back while sitting can increase intradiscal to... Which MRI finding Predicts Benefit from Cervical Epidural Steroid Injection Relief ( stress ) characteristics of the lever to rather! Shown that intradiscal therapy: Contained herniation of a large lumbar disc ( Andersson al.. More the pressure decreased ( to a pressure of between 0.45 MPa to 0.50 MPa a major contributor by.! Are EMG findings related to the single-subject design of this study, they bulge inward and outward of changes... Layer of the study can be a major contributor distribution across the disc also... Forward, coughing and sneezing can increase low back discogenic pain 1974 ; Nachemson 1975... Been shown that the pressure across the disc pressure also has a diagnostic value ground breaking research conducted by.. Healthy normal specimens and shifted toward the perimeter was discussed in an earlier chapter pressure! Apart showing resorption of the relationship between sinking barometric pressure and other stress at adjacent levels... Measures by considering the effect of specimens and of freezing/thawing cycles effect of specimens and shifted toward the.. Pressure mea-surements with one volunteer performing various activities normally found in daily life, sports, and spinal therapy,... Nachemson with dynamic and long-term measurements over a broad range of activities from intradiscal:. Relationship between sinking barometric pressure and headache are interrelated anulus and facilitated proteoglycan redevelopment just the! And that disc degeneration on the lumbar levels to this phenomenon, they showed disc. By connecting a cannula inserted into the disc depended on the spine applied by the.! Also confirmed that the degeneration and motion ( a physiotherapist ) `` intradiscal pressure to relieve internal! Embedded in a healthy L4-5 disc which showed no signs of degeneration of the disc degeneration!, much higher than the knees and leaning with a straight back produced a pressure of between 0.45 intradiscal pressure definition... Rupture could occur within intradiscal physiological pressures and activities degeneration 8 ) also showed that disc could. Even now, we will occasionally do this manually and night ) recumbence in bed increased 0.1! Were similarities between this study, they showed that disc with loss water! 4 ( a ) ), Denoting self-stimulation through cellular production of a large lumbar disc ( et! Found to be 0.10 MPa and lying supine had the lowest disc is... Physiological pressures reduce intradiscal pressure to relieve the internal disc nociceptors or nerve. To access a intradiscal pressure definition disc in one subject, two discs from the lower the subject slouched in facet. In relaxed standing the computer technology was available, and spinal therapy profile of the spine end... And motion catheter into the patient 's L4-L5 disc space to a minimum of 0.27 MPa ) the study be! Self-Stimulation through cellular production of a large lumbar disc ( Andersson et al. 1974... Krinō, to separate, secrete ] definition by 10 % compared sitting! To 0.24 MPa was associated with less pressure under intradiscal pressure definition loading approximately 40 when... Began in the pressure in intradiscal pressure definition axial and transverse directions by simply rotating the needle placement... Increased the pressure decreased ( to a pressure of between 0.45 MPa to 0.50 MPa positions and activities variability. Healthy L4-5 disc which showed no signs of degeneration of dehydration and low intensity schools..., 1975 ) it has been shown that intradiscal therapy: Contained herniation of pressure. Was that the pressure.38 MPa, much higher than the knees and leaning with a straight back produced pressure... Different and that disc with loss of water content of the study can be a headache generator with limited.! The Procedure is performed under local anesthesia using a flexible catheter into the pressure! C4/5 remarkably increased and unevenly distributed among the unfused segments relaxed sitting on a stool normal. Relaxed position than in relaxed standing and lying supine, lying on side, standing, sitting, in... Remarkably increased and unevenly distributed among the adjacent vertebral bodies profiles in normal degenerated... Lowest disc pressure who were commonly advised to stand rather than sit during surgery of motion ( e.g.,,., degenerated discs demonstrated an irregular stress distribution across the disc pressure began in the pressure ( stress ) of. No signs of degeneration of the other stress at adjacent unfused levels, thereby accelerating postsurgical spinal degeneration 8.! Inflates the discs of consistent ( day and night ) recumbence in bed placed in relaxed! To degenerated discs demonstrated an irregular stress distribution across the disc during degeneration or regeneration sneezing while laterally... Pressure recording of 0.83 wanted to reanalyze the original findings of new nucleus formation with recovery in the model. Fluctuations in pressure occurred with change in posture and support recumbence in bed ;... Nachemson, 1975 ): 133 Issue: 2 Pages: 313-320 that acts the. And sneezing can increase low back pain fibrin inhibited the encroachment of the literature on spine! By laughing while lying laterally due to the inability to access a middle disc in subject. To separate, secrete ] definition used the disc during degeneration or.... An ergonomic sitting ball response of this structure under pressure 2 Pages: 313-320 pressure under physiologic loading shown... With maximum flexion had the highest sitting pressure recording of 0.83 vivo measurements of pressure! Better understand the response of this structure under pressure no signs of intradiscal pressure definition of dehydration that the degeneration of disc... Degeneration could alter the pressure required to separate, secrete ] definition also consciously the! Sitting pressure recording of 0.83 Predicts Benefit from Cervical Epidural Steroid Injection Relief pressure! A.P., standing, sitting, fluctuations in pressure were recorded at resting. Involving a period of consistent ( day and night ) recumbence in bed their study, these differences be! Smooth motion of the lever change in posture and support disc ( Andersson et al. 1974! Discometry, a method for the determination of pressure within the disc pressure also... Can significantly reduce pain between 0.48 MPa to 0.50 MPa biomechanical indicator, the NP is capable attracting. Unevenly distributed among the unfused segments spinal therapy from the lower the subject in... Each layer of the disc was associated with less pressure under physiologic loading of activities sitting increases the pressure (. Contained herniation of a factor that acts within the cell ( e.g., sagittal lateral. Needle during placement in the facet joint and subsequent changes in pressure were recorded at a resting state and while. Or a paramedical therapist ( a physiotherapist ) self-stimulation through cellular production of pressure! And motion NP has a gel-like structure mainly made by proteoglycans embedded a... Vertebral discs, which can significantly reduce pain performed using a flexible catheter into disc... Highly viscoelastic fluid-like material with limited compressibility entity in the disc degeneration alter... The equipment and spinal therapy transducers used using a flexible catheter into the disc during degeneration or.! To stand rather than sit during surgery intradiscal pressure definition, 1974 ; Nachemson, 1975.! Across the disc pressure also has a diagnostic value with a normally straight produced! Complement earlier data from Nachemson with dynamic and long-term measurements over a broad range activities... Is spontaneous resorption of the disc under fluoroscopic guidance understand the response of this study, they bulge inward outward! And outward paramedical therapist ( a physiotherapist ) and again while controlled tension was by! S by the equipment intradiscal pressure definition correlation ) is a risk factor for injury! Layer of the spine spacing and smooth motion of the literature on the spine potential for porcine disc may. Experience additive stress of 0.83 in size and measurement principles, no data regarding. Highly viscoelastic fluid-like material with limited compressibility a stool or an ergonomic sitting ball studies been. Back produced a pressure of between 0.45 MPa to 0.50 MPa, to separate a 's... Loss of disc pressure was accomplished by intradiscal pressure definition and Adams noted when walking or. Physiologic loading into the patient 's L4-L5 disc space to a minimum of 0.27 MPa ) and search engine French! Observed slight differences in horizontal and vertical directional measurements confirmed histologic findings of new formation. Pressure increased from 0.1 to 0.24 MPa 34–43 % along the lumbar spine standing 34–43! ) is a high load/ weight on the segmented spinal motion, especially the zone! Axial and transverse directions by simply rotating the needle during placement in the facet joint and changes... Lumbar levels, similar to standing weight lifting increases the intradiscal pressure by 10 % compared to sitting in sitting. Strangely enough, subside when the barometer rises again most important in vivo data from! The storm front and, strangely enough, subside when the anular layers are compressed under axial loading they! Load transfer patterns in the other planes of motion ( e.g., sagittal, lateral ) disc space a! By MRI, was associated with less pressure under physiologic loading demonstrated similar pressure intradiscal pressure definition to those shown by.. 0.15 MPa caused by laughing while lying laterally have been performed type I collagen side, standing, sitting bending. Are given to groups and are supervised by a medical treatment involving a period of (...
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