During the surgery, vertebrae are fused together to heal into a single solid bone, eliminating movement between them and relieving pain. In many cases, surgeons will use plates, screws, and rods to help hold the spine still. For best results, have a successful surgery the first time, Image Evaluations for Out-of-Area Patients, Mayo Clinic Residents and Medical Students, University of Arizona School of Medicine Phoenix, Sonoran Spine Research and Education Foundation, Sonoran Spine in Collaboration with Honor Health Tempe. WebMD does not provide medical advice, diagnosis or treatment. WebActivity Restrictions After Spinal Fusion Surgery. Once the surgeon confirms on x-ray imaging that the fusion has completely solidified into one bone, a full return to an active lifestyleincluding bending, lifting, and twistingis permitted. Every surgery comes with some type of risk. Webkisha e shen palit en rochester. All rights reserved. The goal is to stop movement between the two bones and prevent back pain. Immediately after spinal fusion surgery, recovery begins with a stay in the hospital for at least the first 2-4 days. Harvesting a bone graft requires an additional incision during the operation. has anyone else have if so how are yall doing after bending ? So go ahead -- leave the dishes and laundry to your partner or kids. As we said, in most cases, the vertebrae begin to fuse within 3 to 6 months after surgery. I dropped something and instinctually bent over to pick it up. This helps in promoting healing and fusion of the vertebrae, as well as strengthening the muscles of the back. ", American Academy of Orthopaedic Surgeons: Preparing for Low Back Surgery., Spine Institute of New York: Post-operative., Mater Private Hospital Brisbane: "Spinal care following surgery. WebRecovering From Spinal Fusion. Spine surgery is usually recommended only when your doctor can pinpoint the source of your pain. Often, your insurer's customer service number is printed on the back of your insurance card. ik ur not supposed to bend but i accidentally bent over just now and now im scared ? The goal is to stop movement between the two bones and prevent back pain. Clinical research studies are fundamental to our mission. Dwight Tyndall, MD is a Board Certified and Spine Fellowship trained surgeon, who is recognized as one of the top spine surgeons in the Midwest. Before your doctor sends you home, you'll have spinal X-rays to make sure the fusion is doing OK. You'll return for to have stitches removed in about 10 days. Your doctor will discuss each of the risks with you before your procedure and will take specific measures to help avoid potential complications. They were all asked to rank their pain on a scale of 1 to 10 as to severity, asked about their need for pain medication, and asked about their physical fitness and function. This information is provided as an educational service and is not intended to serve as medical advice. Trends in lumbar spinal fusion A literature review. Ami TR. This surgery often includes the removal of part of or all of the bone that covers the back of the spinal column called the lamina. (i think its the 6 week mark if i remember correctly). You might get out sooner, or you might have to stay about a week. Generally, small pieces of bone are placed into the space between the vertebrae to be fused. (Right) In an anterior lumbar interbody fusion (ALIF), a metallic interbody cage has been inserted to restore the normal height of the disk space. After an orthopedic specialist confirms that the spinal fusion procedure was a success and that the vertebrae have fused as intended. is graham wardle still married to allison wardle; poorest city in north carolina; the coast neighborhood cambridge Advanced techniques. For patients with spinal deformity who required long fusions of many levels in the spine, 80% were still working full time four years after surgery. Tell your doctor right away if you have: After surgery, youll be in the hospital for several days. Infection. 11th ed. Instead of endangering the fusion, exercising the area after 3 months helps it become stronger. Occasionally, surgery may be required to reestablish full function. Talk to your doctor if your pain has not begun to improve within a few days of your surgery. WebJust over 4 weeks post op from L5 S1 360 fusion. Some patients may be discharged from an outpatient spine surgery center directly to a rehabilitation facility. Once theyre fused, they no longer move like they used to. ", Hospital for Special Surgery: "Your Pathway to Recovery: Spine Surgery.". The patients can begin returning to their normal lifestyle again. Press question mark to learn the rest of the keyboard shortcuts. All material on this website is protected by copyright. Bending at the knee and hips is fine. Accessed Nov. 22, 2022. Some drugs, like. So, if you have been told that there is no hope, call Southwest Scoliosis and Spine Institute for an evaluation at214-556-0555or visit ourcontact pagetoday! Mayo Clinic has major campuses in Phoenix and Scottsdale, Arizona; Jacksonville, Florida; and Rochester, Minnesota. Here are some things to think about in the days prior to your surgery: Spinal fusion can be done one of two ways. Some incisions are closed using dissolving stitches or strips that fall off on their own. In order to answer these and other questions related to work after surgery, we conducted a research study through the Sonoran Spine Research and Education Foundation. Make sure your feet Excess bending, lifting, and twisting are still to be avoided in most cases, but graduated exercise, as tolerated, has major benefits. The extended healing period required after lumbar spinal fusion surgery makes postoperative care especially important. Gilbert3717 S. Rome St, Ste 106, Gilbert, AZ 85297, Glendale*Updated Address*6206 W. Bell Rd., Ste 4, Glendale, AZ 85308, North Phoenix 33300 N 32nd Ave, Ste 205, Phoenix, AZ 85085, North Scottsdale (Thompson Peak) 20745 N. Scottsdale Rd, Suite 105, Scottsdale, AZ 85255, Queen Creek37200 N. Gantzel Rd., Ste 240, Queen Creek, Arizona 85140, Scottsdale (Osborn) *New Location*7242 E. Osborn Rd Suite 230, Scottsdale, AZ 85251, Scottsdale (Shea)9700 N. 91st St, Ste B108, Scottsdale, AZ 85258, Show Low4830 Hwy 260, Suite 103, Lakeside, AZ 859291, Sonoran Spine in Collaboration with Honor Health Tempe1255 W Rio Salado Pkwy,Ste 107, Tempe, AZ 85281. Even people wanting to return to strenuous occupations or recreation can typically do so by 6 months after surgery. Back Surgery Video: How Spinal Fusion Stops Back Pain, Learn how bone growth stimulation therapy can help your healing process. 12222 N Central ExpySuite 420Dallas, Texas 75243, 1600 Coit RoadSuite 104Plano, Texas 75075, 5575 Frisco Square Blvd.Suite 240Frisco, Texas 75034, WHAT TO EXPECT AFTER SPINAL FUSION SURGERY, Why Choose Southwest Scoliosis and Spine Institute. These tissues are highly processed, and the chance of infection or disease from this tissue is very low. Know when to arrive at the surgery center. Excluded from the study were patients who were retired, students, the unemployed, and any patients involved in a worker's compensation claim or litigation of any sort (for instance someone involved in a car accident who was suing the driver of the other car). How realistic is it that a person could return to work after spinal fusion? Excess weight increases stress on the back. 1999-2023 Veritas Health, LLC. Your pain level may vary, depending on the location of the spinal fusion. Many people who undergo cervical spinal fusion, for example, report very little pain afterwards. In fact, their previous neck pain often disappears immediately. If you have a lumbar spinal fusion performed, you may experience more discomfort. See the stories of satisfied Mayo Clinic patients. Im not sure how far I bent over but it was definitely more than I was told I could. Though doctors always urge patients to start small, its important to keep increasing the amount of activity throughout this period. Perioperative management in complex spine surgery. Also, they suggest this prevents the brace from rubbing and causing irritation. Surgeons typically recommend keeping the skin around your incision clean and dry for at least 4 days after surgery. Follow your surgeons instructions on when to have sutures or staples removed. || 1 min ago . WebCennina Castle Concert Programme - July & August 2019. During this time, the main goal is finding the balance between taking it easy and maintaining safe activity levels. It increases bone production and helps the vertebrae heal together into a solid bone. Share Twitt Share Pin Comment Twitt Have a list of chores that friends and family can help you with to make it easier to ask for help. As you progress in your recovery, the types of exercises and/or repetitions may be adjusted to help you continue to progress. Login Terms of Use Privacy Policy 2023 Swarm Interactive, Inc. Life After Spine Surgery: Do people really return to work? As you regain strength, you will be able to slowly increase your activity level. 3rd ed. Doctors usually only recommend it if they know exactly what's causing the problem. One alternative to harvesting a bone graft is an allograft, which is cadaver bone. Don't fear the fusion. Illustration of a posterolateral lumbar fusion (PLF) shows bone graft material placed over the transverse processes of the vertebrae. The basic idea is to fuse together two or more vertebrae so that they heal into a single, solid bone. Mayo Clinic in Rochester, Minnesota, Mayo Clinic in Phoenix/Scottsdale, Arizona, and Mayo Clinic in Jacksonville, Florida, are ranked among the Best Hospitals for orthopedics by U.S. News & World Report. Most patients are fully recovered at around 8 months after spinal fusion surgery. You will be taught how to move properly, reposition, sit, stand, and walk. We can help. Also, the therapists can suggest adjustments to the home or workspace. A lot of swelling, redness or drainage by your wound. The purpose of our study was to define the expectations for returning to work for different kinds of spine surgery, from minimal lumbar diskectomy to major spinal reconstruction and fusion of several vertebrae. Share your stories, pictures, failures and successes regarding this condition along with any helpful advice and insight you want to contribute. Minerva Anestesiologica. She and her family love to travel, swim, eat out and spend time outdoors. This exercise program includes pictures and written instructions how to safely perform each movement. At Mayo Clinic, neurosurgeons and orthopedic surgeons use their vast experience with spinal fusion techniques to help provide exactly the treatment and care you need for your specific condition. This site complies with the HONcode standard for trustworthy health information: verify here. Sitting puts the most stress on your back. You might lose movement, but thats rare. Take short walks as often as you can, and gradually increase your distance each day. So what should workers expect from spine surgery? If you cannot reach your doctor, have someone take you to the hospital emergency room or call 911. Even people requiring bigger surgeries like spinal fusion are 90% likely to return to work and stay at work long term. Recovering from back surgery takes commitment and work. Our study showed that a strong majority of patients not only returned to work following spine surgery, but they are able to remain at work long term. Allscripts EPSi. This allows the patient to return to regular daily activities like light chores, driving, and even working (as long as theres no physical activity). Create an account to follow your favorite communities and start taking part in conversations. Just another site. Spinal fusion eliminates motion between vertebrae. Smoking/using other nicotine products (which constricts blood vessels and slows bone growth). Spinal fusion recovery can take anywhere from 4 to 6 weeks up to 3 months, depending on your level of activity. Learn what to expect after different types of spinal fusion surgery, including cervical, lumbar, and spinal fusion for scoliosis. Get a list of the medicines you can or cant take in the days before surgery. The average age of these 255 patients was 45.2 years old with the age ranging from 19 to age 60. The therapists also make sure the patients know how to properly care for their incisions and manage any pain. Accessed Nov. 22, 2022. Webaccidentally bent over after spinal fusion; accidentally bent over after spinal fusion. club xl houseboat netherlands / brigada pagbasa 2021 memo region 5 / accidentally bent over after spinal fusion. If the dura is torn during surgery, it results in more complications (such as leaking of cerebral spinal fluid: CSF 2 ), higher mortality rates, longer hospital stays, increased surgery cost, and a lower hospital discharge rate. Sometimes larger, solid pieces are used to provide immediate structural support to the vertebrae. I think it would take a lot to mess it up. All 255 patients were asked to fill out questionnaires before surgery and at regular intervals after surgery regarding how they felt and how well they were doing. Elsevier Point of Care. WebAdmission Process; Fee Structure; Scholarship; Loans and Financial aid; Programs. ifsac certification is mandatory in ontario. Some had to stop working before surgery due to pain, but they had the capability to work and hoped to get back to work following surgery. There are also different "approaches" your surgeon can take to reach your spine. The back muscles can also be injured during the procedure itself. 3. Follow your surgeons instructions on when and how to bathe. ", American Academy of Orthopaedic Surgeons: "Osteoporosis and Spinal Fractures. Fusion will take away some spinal flexibility, but most spinal fusions involve only small segments of the spine and do not limit motion very much. Your symptoms will gradually improve, as will your activity level. Spinal fusion is surgery to join two or more vertebrae into one single structure. Spinal fusion can be performed in any region of the spine. Spinal surgery is a complex procedure and accidental tearing of the dura occurs in about 2.7% of spine surgeries 4. All rights reserved. The brace is designed to support/stabilize your neck or back and limit movement of the spinal levels fused during surgery. The fusion process takes time. Take short walks as often as you can, and gradually increase your distance each day. This includes bending, lifting excessive weight, or anything that creates a twisting motion that puts stress on the spine segments undergoing fusion. It helps to stimulate bone growth. A lot of patients are concerned about damaging the fusion. Youll need someone to drive you and take you home. accidentally bent over after spinal fusion. An example: 96% of patients were working long term after their first lumbar fusion and 79% of patients were working after revision of a failed fusion attempt. (Related Article: Anterior Lumbar Interbody Fusion), A posterior approach is done from the back. Lumbar and cervical spinal fusion have been performed for decades. Your health care team will go over the details of your procedure. accidentally bent over after spinal fusion . Can a person who has had multiple back surgeries ever work again. So one day, about a month post-op, I was feeling guilty so I tried doing laundry. How long depends on many things, like your general fitness level and if you have any other medical conditions. 4. Most patients are fully recovered at around 8 months after spinal fusion surgery. Take your prescribed pain medicines as directed and make sure to call in refills on time so you are not left with gaps in pain management. Push yourself up using your arms (lead with your top arm) and let your legs bend over the side of the bed so that you end up in a seated position. If you have rods and screws placed on the spine, the angle and placement of the screws is critical to the success or failure of the hardware. In fact, experts often encourage patients to get up and start moving around the morning after their surgery. Repetitive and sudden movements should be avoided. Were here to help STOP THE PAINCall 214-556-0555 or Email Us to make an appointment with our expert scoliosis and spine doctors. Your surgeon may suggest that you wear a brace to help protect the welding process. By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. Ask your surgeon what the best sleep position is for you and how to get into and out of bed. Reddit and its partners use cookies and similar technologies to provide you with a better experience. https://www.uptodate.com/contents/search. Create an account to follow your favorite communities and start taking part in conversations. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). The bone graft is contained within the cage and cannot be seen on X-ray. The right procedure for you will depend on the nature and location of your disease. Sciatic nerve in left leg is pissed off now. Years ago, spine surgery developed a well deserved reputation for causing as much back pain as it helped. After that youll have follow-up appointments, usually in about 4 to 6 weeks, 6 months, 12 months and 24 months. Warning signs of infection include: If any of these symptoms occur, you should contact your doctor or go to the nearest emergency room immediately. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids. Southwest Scoliosis and Spine Institutes board-certified, fellowship-trained orthopedic surgeons, Dr. Richard Hostin,Dr. Shyam Kishan, andDr. Kathryn Wiesman, have the expertise and surgical skills necessary to diagnose and treat these cases. All spinal fusions use some type of bone material, called a bone graft, to help promote the fusion. The instructions did say not to garden or bend, but I was thinking that meant while standing up and bending over. After bone grafting, the vertebrae need to be held together to help the fusion progress. The extra effort you make now can make your recovery smoother and get you back to your normal activities sooner. You'll feel a stretch in your calf. In this X-ray of posterolateral lumbar fusion (PLF), a rod and screws have been used to prevent motion at the spinal segments being fused. While you recover from spinal fusion, you should minimize stress on your back. Driving is not allowed. Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions. People feel so much better that they want to get back to work and stay at work long term. Do not stand or sit for too long. Right after your operation, your doctor may recommend only light activity, like walking. It could take 6 months to a year for your back to fully heal. However, there are factors that can complicate this process and prolong recovery time in some patients, including: If you think you or a loved one might need surgery to correct scoliosis or any other kind of complex spine surgery, its important to contact a surgeon who is skilled in performing these kinds of complicated and specialized procedures. Is Minimally Invasive Spine Surgery Right for You? National Institute of Arthritis and Musculoskeletal and Skin Diseases: "Handout on Health: Back Pain. For patients who had undergone the largest surgeries, long fusions, pre-op pain improved from 7/10 to 3 4/10 at four years. Avoid tub baths until the incision has healed and you are cleared by your surgeon. The majority of patients will not notice a decrease in range of motion. 1 hospital in Minnesota, and the five-state region of Iowa, Minnesota, North Dakota, South Dakota and Wisconsin, according to U.S. News & World Report's 20222023 "Best Children's Hospitals" rankings. Just over 4 weeks post op from L5 S1 360 fusion. See Rehabilitation Following Lumbar Fusion. ", American Academy of Orthopaedic Surgeons: "Adult Spondylolisthesis in the Low Back. Most people stay 4 days. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Katelyn beats scoliosis with new innovative surgery, Mayo Clinic Q and A: Cervical disk replacement, Sharing Mayo Clinic: Complex spine surgery helps Belinda Purdy walk again, Mayo Clinic Q and A: Scoliosis treatment options, Mayo Clinic Minute: When spine surgery is the answer, Mayo Clinic Minute: Scoliosis is not just for kids. It also prevents the stretching of nerves and surrounding ligaments and muscles. Since you will be less active during your recovery, avoid heavy, high calorie, or fattening foods. If your surgeon prescribes a back brace for your recovery, make sure to wear it as instructed. A physical therapist may help guide the start of this exercise program. That said, the vertebrae typically need to continue healing and fusing for between 12 to 18 months. Notify your surgeon immediately if you have fever or chills, night sweats, persistent drainage from your incision, opening of your incision, new onset/worsening pain or weakness, chest pain or shortness of breath, calf pain, or sudden loss of bowel or bladder function. Even patients requiring multiple surgeries are able to work long term after revision surgery. These allow fusions to be performed with smaller incisions. In addition, if there was any nerve damage, it may take up to 2 years for the nerve tissue to heal and return to normal. Spinal fusion is a surgical procedure used to correct problems with the small bones in the spine (vertebrae). It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Some insurers require referrals, or may have additional requirements for certain medical care. For some people, stair climbing may be restricted for the first week or two after surgery. Learn How Bone Growth Therapy Can Help You, Get a Comprehensive Evaluation from Mayo Clinic's Spine Care Experts. An allograft is typically acquired through a bone bank. This procedure involves removing bone and diseased tissues that are putting pressure on spinal nerves. Accessed Nov. 18, 2022. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. We broke down the type of work performed into sedentary (122 patients) medium work (100 patients) heavy work (23 patients) and work type unknown (10 patients). With the added stability from internal fixation, most patients are able to move earlier after surgery. One year following surgery, they noted the pain had improved to about 2 or 3 out of 10. Working with a physical therapist or on their own, patients need to adhere to a long-term exercise program. 1. Avoid even routine activities if twisting of the spine is involved. The theory is if the painful vertebrae do not move, they should not hurt. has anyone else have if so how are yall doing after bending ? Senza categoria. The outpatient surgery center staff will assess your needs and make arrangements for services. Your surgeon will talk with you about whether your specific procedure may impact flexibility or range of motion in your spine. Donor bone graft complications like infection or tissue rejection. Your surgeon may give you suggestions on how long you can sit after surgery before getting up to walk around. A controlled, progressive exercise program is typically started somewhere between 6 weeks and 3 months after surgery. So far Im not experiencing pain in lower back. youll know if somethings wrong from the pain, Things didn't go well at first so I had another surgery. With the latest techniques, we are now able to get people back to work and back to life after spine surgery very reliably. For patients with the smallest surgery, lumbar disc herniation, pain after 4 years was rated 1 or 2 out of 10. The bone is essentially recycled; it is moved from where it is compressing your nerves to the area the surgeon wants to fuse. This is called an anterior approach and requires an incision in the lower abdomen for a lumbar fusion or in the front of the neck for a cervical fusion. Some people get pain medicines through a tube in the back. If you are having a decompression procedure, the surgeon may harvest your bone from the site of the decompression and use it as the graft. Another tube, also called a catheter, connects to where urine normally leaves your body. In: Schwartz's Principles of Surgery. Learn more about the expertise and rankings of Mayo Clinic's neurosurgery and orthopedic surgery departments. Progress in daily activities is usually readily apparent at this stage, and many patients are already working with a physical therapist. Webik ur not supposed to bend but i accidentally bent over just now and now im scared ? It lengthens surgery and can cause increased pain after the operation. I am so overly paranoid about damaging it and having to start over that the smallest thing sends me into panic mode. Physical therapy (PT) may begin as early as the day following surgery. Potential risks and complication of spinal fusion include: It is important that you carefully follow any instructions from your doctor relating to the warning signs of blood clots and infection. Physical therapy is typically started 6 weeks to 3 months after surgery. Spinal fusion is a surgical procedure that links bones in the spinal column together to treat back problems such as herniated disks, fractures, or scoliosis. You're fine, if something went wrong, you'd know! However, the patient eventually transitions to a long-term, self-directed exercise program that can be continued at home. Obtain Long Term Pain Relief. In a posterior approach to lumbar surgery, an incision is made down the middle of the lower back, over the vertebrae to be fused. If this happens, you may experience sudden chest pain and shortness of breath or coughing. Medications are often prescribed for short-term pain relief after surgery. Mayo Clinic. (Related Article: Lateral Lumbar Interbody Fusion). That said, the vertebrae typically need to continue healing and fusing for between 12 to 18 months. So, maintain that positive outlook on life and keep exercising, eating well, and getting plenty of rest, and you can stay on that recovery road for a long time! Our patients tell us that the quality of their interactions, our attention to detail and the efficiency of their visits mean health care like they've never experienced. During the initial stages of recovery and the need to take it easy, patients should not engage in vigorous activity or exercise. This type of graft is called a local autograft. you should be alright, id expect that to go away soon. No lifting anything weighing more than about 8-10 pounds. Bending at the knee and hips are fine, but no bending the back (spine). And, by 6 months after the surgery, most are cleared to start these activities again. All appointments are prioritized on the basis of medical need. Progress in daily Recovery. But in spring 2020, Belinda felt like she was watching the world go by as she sat still. Follow your surgeons instructions on when and how to bathe. After a lumbar spinal fusion has had 3 months of healing, it is time for physical activity and exercise to become a central component of the recovery process. One, called an IV, goes in your arm to give you fluids, antibiotics, and sometimes pain medicines. They can use screws, rods, or pieces of bone (called a graft) from another part of your body to connect the disks and keep them from moving. Screws have been placed to provide stability to the spine while the fusion heals. The joint or joints between the damaged or painful disks are removed. WebSpinal Fusion. Accessed Nov. 18, 2022. fog archetype examples in movies; hallway feeds distinguished; how to read alabama police I also felt helpless and worthless watching my wife do everything for me and our kids. Webto steady the spine. Once the fusion has been found to be progressing as expected, it is no longer as fragile. 5. As with any surgery, there are risks associated with spinal fusion. If you have leg pain or arm pain in addition to back pain, your surgeon may also perform a decompression (laminectomy). (Related Articles: Posterolateral Lumbar Fusionand Posterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion). WebPossible complications of minimally invasive spinal fusion include: Infection Too much bleeding Lack of a solid bone fusion Nerve damage Blood clots There is also a risk that your surgery will not effectively get rid of your pain, or that the surgery might cause a different type of persistent pain at the graft site. We have learned from patients that it is smart to wear a form-fitting undershirt or tank top underneath the brace for comfort. Results from surgery 4 years later - On average, the 255 patients in our study complained of pain of 6 or 7 out of 10 on a scale of 1 to 10 before surgery. A home exercise program is developed for you by the physical therapist under the surgeons direction. Talk to your surgeon about whether you can go up or down stairs. Opioid dependency and overdose have become critical public health issues in the U.S. In some situations where the nerves had significant injury prior to surgery, it may take up to 1 to 2 years to see how well the nerves will heal. WebMuscle Deconditioning. mr rosson royal surrey hospital. WebHere are five ways you can protect your back when you need to bend during your recovery: If you absolutely must pick something up that you dropped, crouch. This is critical for lumbar surgery. You need to stick with physical therapy after you leave the hospital. #5. The healthy habits you adopt as part of your recovery from spine surgery are also great ways to help prevent future or additional spine/health-related problems. After surgery, you will feel some pain. Healing of the deep stitches muscles and soft tissues takes a minimum of 6 weeks. When getting up from a seat, gently move hips to the end of the seat and use your arms to push yourself up with your arms while simultaneously pushing down with your legs.
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