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Supporting the Spine

Jun 09, 2015 09:37AM ● Published by Dia

Above Medical staff of Spine Team Texas in Southlake, Bedford, and Fort Worth-Alliance, Texas.

Exercise can help strengthen the core to combat a prevalent problem: back pain

Back pain can be a terrible culprit that disrupts patients’ lives. And that twinge in the lower back when picking up groceries or the grandkids is increasingly more common among aging baby boomers.

The National Institute of Health reports that 70 to 85 percent of us will experience back pain at some time in our lives, and anyone who has ever felt such discomfort knows what a dramatic impact it can have on daily activity.

Because of the prevalence of back pain and the often unforeseen timing of its onset, questions about back and spine health should be part of every physical exam and patient history.

Luckily, physicians are in a unique position to help patients take up some preventive measures exercises, such as cycling, elliptical training, swimming and learning yoga and Pilates, to ward off back pain before it starts.

Back Pain Etiology

Back pain, complex by nature, can indicate a number of other patient conditions. For example, back pain can point to underlying issues, such as osteoporosis, arthritis, a herniated disc or even a kidney stone. While each of these conditions requires various treatments, sometimes back pain is solely just back pain.  Many times, the two most prevalent causes of back pain are core deconditioning and myofascial pain.

Aging Process

Most commonly, baby boomers suffer from varying degrees of back pain as core deconditioning sets in. The deterioration of back and core muscles can leave the spine and back susceptible to strain and injury and can result in reduced support for the spine.

As the body ages, keeping up back and core body strength takes work, but the benefit is an overall improvement in wellness. Let's not forget that exercise can lead to weight loss, which can also alleviate back pain in some overweight patients.

For general wellness, individuals should exercise for a minimum of 30 minutes a day, three times a week. Certain exercises are ideal for strengthening the core, thereby reducing the risk of back pain. These exercises all share low-impact characteristics.

Cycling. Cycling is a relatively nonweight-bearing exercise. It also engages some of the largest muscles in the body.  Adopting a cycling routine can help build muscle mass and improve balance, both of which can help individuals prevent back injury in the future. To ensure that patients reap the benefits of the time spent cycling, physicians can do more than tell them to get out and ride the roads; they should also stress getting the right fit.

Normally, a local bike shop can offer a personalized evaluation to ensure the bike is adjusted for each person. If a bike is the wrong size, patients could end up increasing their risks for back pain instead of decreasing those risk factors. 

A stationary bike also can provide patients with similar benefits that a traditional bike offers, but may be a safer option. 

Swimming. Swimming is also a phenomenal exercise for patients who are looking to prevent or recover from back pain. This aerobic exercise is joint-friendly and can help a patient build muscle without strain as it does not place weight on the back.

Encourage your patients to pick the strokes that he or she would like to perform carefully if swimming is part of a physical therapy routine. For example, if a patient is experiencing pain in the cervical (upper) spine, he would not want to do a freestyle stroke that requires turning the head quickly from side to side. Additionally, water aerobics is a very low impact cardiovascular work out that can strengthen muscles and endurance.

Elliptical work. If jumping into the deep end doesn’t appeal to a patient, elliptical work can also provide benefit for patients with low back pain. These machines have cropped in gyms across the country during the last few years, and many patients may decide to purchase an elliptical for their home gym as well.

Unlike running on a treadmill, walking or running with an elliptical machine does not cause harmful pressure to joints, thus it delivers a good cardiovascular workout that is low impact while still helping to build important muscle mass.

Elliptical machines also use a passive motion, stopping when the individual stops, which can be safer than a treadmill when it comes to the safety of one’s joints. For all exercises, it is imperative to maintain correct form. For example, stress that patients should be in an upright posture on the elliptical machine and avoid stooping over, particularly when fatigue begins.

Classes. Perhaps the place that a patient will hear most about core body strength is in yoga and Pilates classes.  Yoga courses focus on stretching, breathing exercises, muscle contractions, balance exercises and meditation.  Pilates classes specifically focus on the lower back and abdomen and “centering” and controlling the body.  The strength and flexibility training each of these disciplines offer can be incredibly beneficial to patients looking to prevent back pain as they focus on building core strength and increasing flexibility.

The other ongoing benefit of these types of programs is that they make a patient increasingly aware of his/her posture.  Not all yoga and Pilates classes are the same though.  If a patient seems interested in pursuing this option for physical exercise, then recommend that he or she first has a discussion with the instructor. 

Letting the instructor know about any limitations, preexisting conditions, and motivations for taking the class can help him or her recommend a pace and/or modifications that should be considered to certain movements.

In addition, a patient who has a yoga mat handy can also perform basic abdominal strengthening exercises in the comfort of his or her own home. Crunches, heel slides, leg raises, leg lifts and abdominal contractions can all contribute to stronger core muscles and a more protected spine.

Strength training. Obviously, low-impact exercises offer a great way to bolster the back. However, premenopausal women especially need to consider some type of weight-bearing exercise to prevent osteoporosis. Men should also keep this in mind as well because osteoporosis in men is becoming increasingly prevalent.

Working with dumbbells, cable or weight machines can increase muscle and bone strength, which becomes more important for women as they age. This exercise, in addition to taking calcium, has especially benefited this patient demographic.

Occupational Hazards

As back pain dominates many patients’ lives, we have to be vigilant in prevention efforts--especially if daily life exposes patients to certain risk factors. 

Certain occupations can naturally exposed patients to higher risk factors; any job that entails excessive sitting, standing, or manual labor can lead to an increased likelihood of back pain.  For example, if your patient is a call center representative, he or she may be required to sit at his or her desk for a long, regimented length of time.

You can recommend standing up at least once an hour and discuss the components of an ergonomically friendly workstation.  If sitting is absolutely required for long periods of time, you may also want to recommend an exercise ball for the patient to use in lieu of a chair for a given period of time during the day. Sitting on an exercise ball allows the spine to move and allows the core muscles to stabilize the spine.  And, exercise balls encourage good posture.  A number of exercises, both traditional and incorporating an exercise ball, can ease back pain.

If the patient is a teacher who is on his/her feet all day or a construction worker who lifts heavy objects regularly, posture is also an important topic to discuss.  More importantly, a physician needs to discuss body mechanics with these patients, like lifting techniques for patients performing manual labor. Likewise, good cardiovascular conditioning can give patients in these professions the needed endurance and muscle strength to avoid back pain when performing their everyday duties.

Core Conditioning

Each physician should be able to go over the basics of a core conditioning regimen for patients with some type of back pain or who have a history of back pain. However, if a patient has low back pain symptoms, physicians should refer to a spine specialist before embarking on a new program. A specialist is best qualified to diagnose the pain and can further discuss the best types of exercise for a patient to try. This will ensure that the exercise recommended will not exacerbate or cause any discomfort.

While limited bed rest can certainly provide short-term relief to back pain, abstaining from normal activity for too long causes more harm than benefit. We hardly ever recommend extended bed rest because back muscle and cardiovascular conditioning are keys to the healing process.

Even if it’s too late to prevent back pain, exercise can ease or alleviate back pain. Most types of back pain markedly improve with physical therapy exercises. Individualized exercise regimens can help manage symptoms and allow patients to return to daily life. And, sometimes, starting off a routine with a physical therapist is just the push a patient needs to stick with the program. 

Certainly, some types of exercises will prove more benefit than others, but physicians should stress exercising in whatever way makes patients feel most comfortable.  Any one of the above exercises releases the natural painkillers endorphins that can help patients overcome even minor back soreness and stiffness. Thus, stress this to patients, especially those in high-risk occupations, that we can improve back pain by incorporating a more active approach.

 

Sidebar:

Best Exercises to Prevent Back Pain

·      Walking

·      Cycling

·      Swimming

·      Elliptical Machine

·      Yoga

·      Pilates

·      Weight Training (as recommended by a physical therapist or physician)


About Spine Team Texas

 Spine Team Texas specializes in the treatment of back and neck problems ranging from simple back or neck strains to the most complex spine surgeries. Through its in-depth knowledge and true team approach, Spine Team Texas is dedicated to treating patients conservatively through education, physical therapy, non-surgical treatments, and minimally invasive spine surgery when necessary. The philosophy of Spine Team Texas is to treat with an emphasis on non-surgical treatment whenever possible and consider surgical intervention only as a last resort when non-surgical measures have failed to provide long-term relief.  The team consists of physical medicine and rehabilitation physicians, specializing in non-surgical spine care; spine surgeons trained in the latest minimally invasive spine surgery techniques; spine pain anesthesiologists focused on chronic spine pain; spine-focused physical therapists and on-site registered nurses. Established in December 2004, Spine Team Texas is headquartered in Southlake, Texas, and opened a full-spectrum sister facility in Rockwall, Texas, in March 2009. Other locations include Bedford, Fort Worth-Alliance, and North Dallas-Richardson.  In 2012, Spine Team Texas built two, free-standing,  joint venture ambulatory surgery centers (in Southlake and Rockwall).  With approximately 175 employees, Spine Team Texas has received numerous awards such as ‘Best Places to Work’ & “Healthcare Heroes-Physician Award by Dallas Business Journal, “Top Docs” in Fort Worth, Texas magazine, U.S. News & World Report “Top Docs” in neurosurgery, “Top Docs” in neurosurgery & physical medicine and rehabilitation by Castle-Connelly, D Magazine “Best Docs” in orthopedic surgery and physical medicine and rehabilitation, Becker’s Spine Review “Top 105 Spine Surgery Practices to Know” & “Spine Leadership Award” in 2013.   For more information about Spine Team Texas, visit www.SpineTeamTexas.com.  Follow/”Like” them Twitter, YouTube and on Facebook at:  www.facebook.com/spineteamtexas.



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    "Texas Best" Christmas Lights (as voted by the viewers of the Texas Country Reporter TV Show) are...


  • Shop for handcrafted finds and support the local artisans responsible for them. Each local artisa...


  • Extreme Ornament Help-Create Events

    12/24/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/24/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/24/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/24/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/24/2017
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/24/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • Interlochen Lights 2017

    12/24/2017
    07:00PM — 11:00PM

    "Texas Best" Christmas Lights (as voted by the viewers of the Texas Country Reporter TV Show) are...


  • Extreme Ornament Help-Create Events

    12/25/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/25/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/25/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/25/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/25/2017
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/25/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • Interlochen Lights 2017

    12/25/2017
    07:00PM — 11:00PM

    "Texas Best" Christmas Lights (as voted by the viewers of the Texas Country Reporter TV Show) are...


  • Dine For Dragons: December 26

    12/26/2017
    07:00AM — 12:00AM

    Eat in. Take out. Help fuel Carroll Education Foundation with every meal on December 26. Restaura...


  • Winter Mystery Basket Camp (Ages 4-8)

    12/26/2017
    09:00AM — 12:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Winter Mystery Basket Camp (Ages 9-Teen)

    12/26/2017
    01:00PM — 04:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Extreme Ornament Help-Create Events

    12/26/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/26/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/26/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/26/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/26/2017
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/26/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • Interlochen Lights 2017

    12/26/2017
    07:00PM — 11:00PM

    "Texas Best" Christmas Lights (as voted by the viewers of the Texas Country Reporter TV Show) are...


  • Winter Mystery Basket Camp (Ages 4-8)

    12/27/2017
    09:00AM — 12:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Winter Mystery Basket Camp (Ages 9-Teen)

    12/27/2017
    01:00PM — 04:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Extreme Ornament Help-Create Events

    12/27/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/27/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/27/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/27/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/27/2017
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/27/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • Winter Mystery Basket Camp (Ages 4-8)

    12/28/2017
    09:00AM — 12:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Winter Mystery Basket Camp (Ages 9-Teen)

    12/28/2017
    01:00PM — 04:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Extreme Ornament Help-Create Events

    12/28/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/28/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/28/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/28/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/28/2017
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/28/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • Winter Mystery Basket Camp (Ages 4-8)

    12/29/2017
    09:00AM — 12:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Winter Mystery Basket Camp (Ages 9-Teen)

    12/29/2017
    01:00PM — 04:00PM

    Calling all chefs! Cooking shows have nothing on Taste Buds Kitchen's tasty cooking extravaganzas...


  • Extreme Ornament Help-Create Events

    12/29/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/29/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/29/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/29/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/29/2017
    05:00PM — 11:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/29/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • PARTY ON!

    12/29/2017
    07:00PM — 10:30PM

    Join us each Friday night for our weekly ballroom dance party! A great mix of ballroom, latin, c...


  • Extreme Ornament Help-Create Events

    12/30/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Traditional Ornament Help-Create Events

    12/30/2017
    02:00PM — 06:00PM

    Bring the kids and drop in for one of Vetro’s Traditional Ornament Help-Create events, *select da...


  • Holiday in the Park 2017

    12/30/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    12/30/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    12/30/2017
    05:00PM — 11:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Gift of Lights 2017

    12/30/2017
    06:00PM

    The Gift of Lights is a Texas-sized Drive Thru light park hosted at Texas Motor Speedway with a p...


  • Extreme Ornament Help-Create Events

    12/31/2017
    02:00PM — 06:00PM

    Unleash your inner elf during Vetro’s Extreme Ornament Help-Create events, *select dates and time...


  • Holiday in the Park 2017

    12/31/2017
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    12/31/2017
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Enchant Christmas Light Maze & Market

    12/31/2017
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • Ring in New Years Eve at Truluck's

    12/31/2017
    05:00PM — 12:00AM

    This New Year's Eve (December 31), Truluck's has two options for diners to ring in the New Year: ...


  • Toast to the New Year with Moët & Chandon champagne and a five-course dinner in LAW before dancin...


  • New Year's Day Hangover Brunch at Four Seasons

    01/01/2018
    10:00AM — 02:00PM

    Start 2018 off right with an indulgent brunch and build your own Bloody Mary bar in LAW.


  • New Year's Day Hangover Brunch at Four Seasons

    01/01/2018
    10:00AM — 02:00PM

    Start 2018 off right with an indulgent brunch and build your own Bloody Mary bar in LAW.


  • Holiday in the Park 2017

    01/01/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • Enchant Christmas Light Maze & Market

    01/01/2018
    05:00PM — 11:00PM

    The Lone Star State is about to get a lot brighter as Enchant, The World's Largest Christmas Ligh...


  • 2017 Magical Winter Lights

    01/01/2018
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/02/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/02/2018
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/03/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/03/2018
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/04/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/04/2018
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/05/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/05/2018
    05:00PM — 11:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/06/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/06/2018
    05:00PM — 11:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/07/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/07/2018
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


  • Holiday in the Park 2017

    01/08/2018
    02:00PM — 10:00PM

    Holiday in the Park is back for select days from November 17-January 7 at Six Flags Over Texas. I...


  • 2017 Magical Winter Lights

    01/08/2018
    05:00PM — 10:00PM

    Magical Winter Lights is a spectacular, larger-than-life festival that presents a fresh multicult...


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