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may be diminished by a light lumbosacral support, but many orthopedists refrain from prescribing this aid As a result of several studies that have failed to demonstrate a bene t of bed rest, recent practice has been to mobilize patients as soon as they are able and to prescribe corrective exercises designed to stretch and strengthen trunk (especially abdominal) muscles, overcome faulty posture, and increase the mobility of the spinal joints Despite this modern approach, the authors can af rm from personal experience that some injuries produce such discomfort that arising from a bed or chair is simply not possible in the early days after injury The use of spinal manipulation practiced by chiropractors, osteopaths, and others has always been a contentious matter in the United States, partly because of unrealistic therapeutic claims made in treating diseases other than low back derangements By contrast, in certain parts of Europe, orthopedists often incorporate manipulative procedures into conventional practice A type of slow muscle stretching and joint distraction (axial traction on a joint) administered by physiatrists and physical therapists is quite similar It must be recognized that many patients seek chiropractic manipulation on their own, often before seeing a physician, and may not disclose this information to the physician When the supporting elements of the spine (pedicles, facets, and ligaments) are not disrupted, chiropractic manipulation of the lumbar spine has provided acute relief to a considerable number of our patients with low back strain or facet pain; at issue is the durability of the effect, even with repeated so-called spinal adjustments A randomized British trial has shown manipulation to be superior to analgesics and bed rest in returning patients to work after minor back injury (Meade et al) Some other trials have corroborated this nding (Hadler et al), while others have not, or, most often, the results have been ambiguous In the study by Cherkin and colleagues comparing chiropractic, physical therapy (McKenzie method), and simple instruction to the patient from a booklet, manipulation yielded a slightly better outcome at the end of a month Despite several hypotheses offered by practitioners of spinal manipulation, the mechanism of pain relief is not known The sound created by rapid and forceful distraction of the facet joints, similar to cracking the knuckles, seems not to be necessary for pain relief Whether all forms of low back pain represent minor subluxations, as claimed by chiropractors, is undocumented and seems unlikely Chronic low back pain has, in the authors experience, been less successfully treated by manipulative procedures, but there are some patients who testify to improvement in their clinical state, and admittedly the medical profession has little to offer many of these patients The results with another popular approach, acupuncture, have been even more uncertain for acute or chronic back pain, most studies showing it to be no more effective than a sham treatment (Tudler et al) It should be added, however, that the commitment of patients to a regimen of NSAIDs for many months or to narcotic analgesics is a hazard always to be avoided The Degenerative Low Back Syndrome Often the symptoms of low back strain are recurrent and more chronic in nature, being regularly exacerbated by bending or lifting, suggesting that postural, muscular, and arthritic factors play a role This is the most common syndrome seen in orthopedic clinics, more in men than in women After some unusual activity, raising the question of trauma, especially if it happens in the workplace, the patient develops deep aching pain in the low back, increased by certain movements and attended by stiffness The pain may additionally have a restricted radiation into the buttocks and posterior thigh, thereby simulating.

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When the Oracle database executes a query on the Oracle Exadata Database Machine, it will use a combination of optimizations traditionally provided by the Oracle database and optimizations that are specific to the Oracle Exadata Database Machine and Oracle Exadata Storage Server Software So, as we illustrate the typical life of a query, we take into account several of the optimizations that we have already covered in this chapter In our example, the Oracle data warehouse contains seven years of customer data and requires 50TB of storage space to contain the data The data in the database columns contains a significant number of repeating values The data is partitioned in composite partitions by geographic region

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