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Gym Equipment Explained: Balance Cushion

FitSugar — Tue, 17 Jul 2007 11:45:00 -0700

Most gyms have these odd looking inflatable discs, but what the heck do you do with it?

Inflatable Balance Disc/Cushion
What is it: A small inflatable cushion/disc that adds an element of instability to a workout. The cushion is typically textured on one side to control tread and minimize tipping. You can easily control the balance challenge by adjusting the inflation (less inflated it is, the harder).
Area of Body it Works: Core and more (depends entirely on how you use it)
Why: The instability, maximizes effort during functional training-- Good for a strong core and lower back.
How: There are many ways you can use the disc but here are some easy ideas --

Place a cushion under your foot/feet when doing squats and lunges.
Place two under your feet when doing sit-ups on an exercise ball.
Place one under your low back when doing crunches on the floor.
Place two under your hands (or one under your feet) during push-ups.
Place one disc under your feet while doing calf raises to strengthen ankles, calves and thighs.
Place one under your hands or feet during a plank.
Place one under your booty while sitting on an average chair to increase the strength of your lower abdomen and back muscles, reducing your risk of back injury from sitting all day.

If you have your own use for the balance cushion, share it with us in the comments section below.

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Win a Pair of New Balance Lace Up For the Cure Running Shoes

FitSugar — Tue, 13 Oct 2009 09:33:53 -0700

New Balance knows that exercise helps prevent breast cancer. So we teamed up with this sporty company to promote breast cancer awareness, and are giving away five pairs of New Balance Lace Up For the Cure 769 pink sneakers.

Starting today you can enter to win a pair of these well-cushioned, stylish sneaks. To participate in the giveaway, just take this quiz on breast cancer prevention. Your eligibility is not based on your score; simply taking the quiz once you have logged in will enter you in the contest. You do, however, need to be a PopSugar Community member to enter. So if you're not already one, register here now. You can read the official rules here, but do note that we accept one quiz entry per person; all repeat quizzes will be ignored. Prizes can be shipped to US destinations only. The contest ends Oct. 13 at midnight PDT, so get cracking on the quiz!

Take the quiz

What's Most Important When Buying New Sneaks?

FitSugar — Thu, 10 Sep 2009 03:47:38 -0700

I recently went shopping for new sneakers. Fit was definitely my number one priority when I picked up a pair of these New Balance 769. While running on the treadmill in the store, these sneaks offered stability and cushioning and were lightweight - exactly what I was looking for.

I know you probably take a few things into consideration when buying new sneaks, but what's the most important?

Foot pain

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Treatment: Corns and Callus...
Treatment: Bunions
Treatment: Hammertoes
Treatment: Ingrown Toenails...
Treatment: Forefoot Pain...
Treatment: Heel Pain
Treatment: Flat Feet
Treatment: Abnormally High ...
Treatment: Tarsal Tunnel Sy...
Treatment: Foot Injury
Prevention
Shoes
Insoles and Orthotics
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Treatment for Ingrown Toenail:

Orthonyxia, a surgical technique that implants a small metal brace into the top of the nail, was as effective as traditional surgical techniques for preventing ingrown toenail from recurring, according to one study.
A nonsurgical method for treating ingrown toenail with chemicals uses either sodium hydroxide or phenol, but one study shows that sodium hydroxide procedures have a better outcome and faster recovery than phenol procedures.

Treatment for Forefoot Pain:

Ultrasound-guided injection of alcohol might provide relief from Morton's neuroma, according to one study. Symptoms improved in 94% of patients who had the treatment, a success rate comparable to that of surgery.

Treatment for Heel Pain:

NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.
Studies show that extracorporeal shockwave therapy provides a very small reduction in heel pain without side effects. It may be a good option for patients who haven't responded well to conservative treatment.

Work-related Foot Problems:

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work.

Introduction

Foot pain is very common. About 75% of people in the United States have foot pain at some time in their lives. Most foot pain is caused by shoes that do not fit properly or that force the feet into unnatural shapes (such as pointed-toe, high-heeled shoes).

The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of more than 120 muscles, ligaments, and nerves. It serves the following functions:

Supports weight
Acts as a shock absorber
Serves as a lever to propel the leg forward
Helps maintain balance by adjusting the body to uneven surfaces

Because the feet are very small compared with the rest of the body, the impact of each step exerts tremendous force upon them. This force is about 50% greater than the person's body weight. During a typical day, people spend about 4 hours on their feet and take 8,000 - 10,000 steps. This means that the feet support a combined force equivalent to several hundred tons every day.

Foot pain generally starts in one of three places: the toes, the forefoot, and the hindfoot.

The Toes. Toe problems most often occur because of the pressure imposed by ill-fitting shoes.

The Forefoot. The forefoot is the front of the foot. Pain originating here usually involves one of the following bone groups:

The metatarsal bones (five long bones that extend from the front of the arch to the bones in the toe)
The sesamoid bones (two small bones embedded at the top of the first metatarsal bone, which connects to the big toe)

The Hindfoot. The hindfoot is the back of the foot. Pain originating here can extend from the heel, across the sole (known as the plantar surface), to the ball of the foot (the metatarsophalangeal joint).

Condition	Location	Symptoms	Recommended Footwear
Toe Pain
Corns and calluses	Around toes, usually little toe, bottom of feet or areas exposed to friction.	Hard, dead, yellowish skin.	Wide (box-toed) shoes; soft cushions under heel or ball of foot, or customized or gel insoles for calluses. Doughnut-shaped pads for corns.
Ingrown toenails	Toenails.	Nail curling into skin causes pain, swelling, and, in extreme cases, infection.	Sandals, open-toed shoes.
Bunions and bunionettes (tailor's bunion)	Big toe (bunions) or little toe (bunionettes).	The following can occur alone or in combination: Metatarsus primus varus. The first (big toe) metatarsal bone shifts away from the second, and the big toe points inward. Medial exostosis. This is a bony bump at the base of the big toe, which protrudes outward. Area next to bony bump is red, tender, and occasionally filled with fluid. Toe joint may be inflamed. Hallux valgus. This is a deformity in which the bone and joint of the big toe shift and grow inward, so that the second toe crosses over the big toe.	Soft, wide-toed shoes or sandals. Bunion shields or splints. Thick doughnut-shaped moleskin pads, custom-made orthotics or foot slings, if necessary. Avoid shoes with stitching along the side of the "bump."
Morton's neuroma (also called interdigital neuroma)	Inflammation of the nerve, usually between the third and fourth toes and bottom of the foot near these toes.	Cramping and burning pain, or electric-shock sensation. The condition may produce a thick protective sheath around the nerve that feels like a ball. This may be detected by pressing top to bottom on the top of the foot using one hand and moving the other hand from side to side. Morton's neuroma is aggravated by prolonged standing and relieved by removal of the shoes and forefoot massage.	Wide (box-toed) shoes. Orthotic or insole with pad that reduces stress on the painful area.
Hammertoe or claw toe	Usually second toe, but may develop in any or all of the three middle toes.	Toes form hammer or claw shape. In hammertoe, the first knuckle of the toe is mainly affected. In claw toe the entire toe is deformed. No pain at first, but pain increases as tendon becomes tighter and toes stiffen.	Wide (box-toed) shoes. Toe pads or specially designed shields, splints, caps, or slings. (Splints or slings are not for people with diabetes.)
Front-of-the-Foot Pain
Metatarsalgia	Ball of the foot.	Acute, recurrent, or chronic pain without a known cause.	Wide (box-toed) shoes. Orthotic with pad that reduces metatarsal pressure. Gel cushions. Metatarsal bandage.
Stress fracture	Most often in the area beneath the second or third toe.	Sudden pain (which persists) when injury occurs.	Low-heeled shoes with stiff soles.
Sesamoiditis	Ball of foot beneath big toe.	Pain and swelling.	Low-heeled shoe with stiff sole and soft padding inside.
Heel and Back-of-the-Foot Pain
Plantar fasciitis or heel spurs	Back of the arch right in front of heel.	At onset, some people report a tearing or popping sound. Pain is most severe with first steps after getting out of bed. Pain decreases after stretching, returns after inactivity.	Over-the-counter foot insole (cut quarter-size hole surrounding painful area). Possible night splints. Orthotics if necessary.
Bursitis of the heel	Center of the heel.	Pain, with warmth and swelling. Increases during the day.	Heel cup.
Haglund's deformity (pump bump)	Fleshy area on the back of the heel.	Tender swelling aggravated by shoes with stiff backs.	Soft shoes. Heel pads. Possible orthotic to support heel.
Achilles tendinitis	Achilles tendon: area along the back between calf muscles and heel.	Pain worsens during physical activities (particularly running), after which the tendon usually swells and stiffens. If it ruptures, popping sound may occur followed by acute pain similar to a blow at the back of the leg.	Insoles, tendon strap, heel cups.
Arch and Bottom-of-the Foot Pain
Tarsal tunnel syndrome	Anywhere along the bottom of the foot.	Numbness, tingling, or burning sensations, pain, most commonly felt at night.	Specially designed orthotics to relieve pressure.
Flat feet or posterior tibial tendon dysfunction (PTTD)	The arch.	No arch. Often no pain or discomfort. Three stages in PTTD: Pain and weakness in the tendon. The arch flattens but is still flexible. The foot becomes rigid and possibly painful at the ankle. Sometimes people report fatigue, pain, or stiffness in the feet, legs, and lower back.	For children, possible custom-made insoles.
High arches (hollow feet)	The arch.	High arches. Lower back pain, possible tendency to lower limb injuries.

Causes

Nearly all causes of foot pain can be grouped under one of the following:

Ill-fitting shoes. Poorly fitting shoes are a frequent cause of foot pain. High-heeled shoes concentrate pressure on the toes and can aggravate, if not cause, problems with the toes.
Certain medical conditions. Any medical condition that causes a disturbance in the way a person walks can contribute to foot pain. This may include diseases or conditions that lead to pain or numbness in the feet (such as diabetes), leg and foot deformities, spinal problems, and neurological disorders such as Parkinson's disease or cerebral palsy.
High-impact exercise. High-impact exercising, such as jogging or strenuous aerobics, can injure the feet. Common injuries include corns, calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar fasciitis, and metatarsalgia.

Arthritic Conditions. Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected.

Diabetes. Diabetes is an important cause of serious foot disorders. [For more information, see In-Depth Report #9: Diabetes - type 1 and In-Depth Report #60: Diabetes - type 2.]

Obesity. Obesity can cause foot and ankle pain.

Pregnancy. Pregnancy can cause fluid buildup and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress.

Medications. Some medications, such as calcitonin and drugs used for high blood pressure, can cause foot swelling.

Click the icon to see an image of foot inspection.

Risk Factors

A risk factor is anything that increases your chances of getting a disease or condition. The following are factors that increase your risk for foot pain:

Elderly people are at very high risk for foot problems. As you age, your feet widen and flatten, and the fat padding on the sole of the foot wears down. The skin on the feet also becomes dryer. Foot pain in older adults may be the first sign of age-related conditions, such as arthritis, diabetes, and circulatory disease. Foot problems can also impair balance and function in this age group.

Taking fashion to extreme limits, some people have turned to cosmetic surgery as a drastic way to fit into high-heeled shoes. Procedures include surgical shortening of the toes, narrowing of feet, or injecting silicone into the pads of the feet. Such methods may increase your risk for future foot pain. The American Orthopaedic Foot and Ankle Society (AOFAS) and other foot-related medical associations have expressed concern over this trend. The AOFAS strongly advises against cosmetic foot surgery and urges consumers to carefully consider the relative risks and benefits of undergoing unnecessary surgical procedures.

Women are at higher risk than men for severe foot pain, probably because of high-heeled shoes. Severe foot pain appears to be a major cause of general disability in older women.

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems -- including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot, and tarsal tunnel syndrome -- have been attributed to repetitive use at work.

For example, in a study of New York police officers who walked an average of 3 miles a day, 20% experienced foot pain at the end of their workday. (Insoles can relieve much of this pain.) No studies, however, have scientifically distinguished between injuries due to work versus those due to regular use. This is an important issue because of its potential impact on disability claims.

Pregnant women have an increased risk of foot problems due to weight gain, swelling in their feet and ankles, and the release of certain hormones that cause ligaments to relax. These hormones help when bearing the child, but they can weaken the feet.

People who engage in regular high-impact aerobic exercise are at risk for plantar fasciitis, heel spurs, sesamoiditis, shin splints, Achilles tendon, and stress fractures. Women are at higher risk for stress fractures than are men.

Gaining weight puts added stress on the feet and can lead to foot or ankle injuries. The added pressure on the soft tissues and joints of the foot in overweight people increases the likelihood of developing tendinitis and plantar fasciitis.

Treatment: Corns and Calluses

A corn is a protective layer of dead skin cells that forms due to repeated friction. It is cone-shaped and has a knobby core that points inward. This core can put pressure on a nerve and cause sharp pain. Corns can develop on the top of, or between, toes. If a corn develops between the toes, it may be kept pliable by the moisture from perspiration and is therefore called a soft corn.

Corns develop as a result of friction from the toes rubbing together or against the shoe. They often occur from the following:

Shoes, socks, or stockings that fit too tightly around the toes
Pressure on the toes from high-heeled shoes
Shoes that are too loose, due to the friction of the foot sliding within the shoe
Deformed and crooked toes

Calluses are composed of the same material as corns. Calluses, however, develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily about 40 times thicker than the skin anywhere else on the body, but a callus can even be twice as thick. A protective callus layer naturally develops to guard against excessive pressure and chafing as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, they may pull and tear the underlying skin.

Risk factors for calluses include the following:

Poorly fitting shoes
Walking regularly on hard surfaces
Flat feet

Of note, in people with diabetes, the presence of calluses is a strong predictor of ulceration, particularly in those who have a history of foot ulcers.

Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and calluses and relieve discomfort if they develop:

Do not wear shoes that are too tight or too loose. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have a cobbler stretch the shoes in the area where the corn or callus is located.
Wear thick socks to absorb pressure, but do not wear tight socks or stockings.
Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them.
Use doughnut-shaped pads that fit over a corn and decrease pressure and friction. They are available at most drug stores.
Place cotton, lamb's wool, or mole skin between the toes to cushion any corns in these areas.

Removing Corns and Calluses. To remove a corn or callus, soak it in very warm water for 5 minutes or more to soften the hardened tissue, then gently sand it with a pumice stone. Several treatments may be necessary. Do not trim corns or calluses with a razor blade or other sharp tool. Unsterile cutting tools can cause infection, and it is easy to slip and cut too deep, causing excessive bleeding or injury to the toe or foot.

Medicated Solutions and Pads. There are numerous over-the-counter pads, plasters, and medications for removing corns and calluses. These treatments commonly contain salicylic acid, which may cause irritation, burns, or infections that are more serious than the corn or callus. Use caution with these medications. The following people should not use them:

Patients with diabetes
Patients with reduced feeling in the feet due to circulation problems or neurological damage
Patients who do not have the flexibility or eyesight to use them properly

Treatment: Bunions

A bunion is a deformity that usually occurs at the head of one of the five long bones (the metatarsal bones) that extend from the arch of the foot and connect to the toes. A bunion typically develops in the following way:

Most often it occurs in the first metatarsal bone (the one that attaches to the big toe). A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as either a bunionette or a tailor's bunion.
A bunion begins to form when the big or little toe is forced in toward the rest of the toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.
The underlying tissue becomes inflamed, and a painful bump forms.
As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle toward the rest of the toes. One important bunion deformity, hallux valgus, causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.

Several conditions can cause bunions:

Narrow high-heeled shoes with pointed toes can put enormous pressure on the front of the foot.
Injury in the joint may cause a bunion to develop over time.
Genetics play a role in 10 - 15% of all bunions.

Flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet can also increase the risk for bunions.

Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:

Soft, wide, low-heeled leather shoes that lace up
Athletic shoes with soft toe boxes
Open shoes or sandals with straps that don't touch the irritated area

A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injections may offer some pain relief.

Surgery. If discomfort persists, surgery may be necessary, particularly for more serious conditions, such as hallux valgus. There are more than 100 surgical variations, ranging from removing the bump to realigning the toes.

The most common surgery, an office procedure known as bunionectomy, involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. This technique is not a cure, but patient satisfaction is high and results are long-lasting.

Click the icon to see an illustrated series detailing bunion removal.

More extensive surgeries may be required to realign the toe joint. Although there are variations of each, they generally involve one or more of the following:

Osteotomy (cutting and realigning the joint). Long-term studies on osteotomies report that 90% of patients are satisfied with the procedure.
Exostetectomy (removal of the large bony growth). This technique is only useful when there is no shift in the toe bone itself.
Arthrodesis (removal of damaged portion of the joint, followed by implantation of screws, wires, or plates to hold the bones together until they heal). This is the gold standard procedure for very severe cases or when previous procedures have failed. Most patients report good results.
Arthroplasty (removal of damaged portion of the joint with the goal of achieving a flexible scar). This technique offers symptom relief and faster rehabilitation than arthrodesis, but it can cause deformity and some foot weakness. Arthroplasty tends to be used in older patients. Biologic or synthetic implants for supporting the toes are showing promise as part of this procedure.
Tendon and Ligament Repair. If tendons and ligaments have become too loose, the surgeon may tighten them.

In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or damage from osteoarthritis.

Complications, though uncommon in even the most complex procedures, can include:

Continued pain
Infection
Possible numbness
Irritation from implants used to support the bone
An excessively shortened metatarsal bone

Recovery from more invasive procedures, such as arthrodesis or osteotomy, may take 6 - 8 weeks, and it can be that long before a patient can put full weight on the foot. In such cases, the patient will need to wear a cast or use crutches. Elderly patients may need wheelchairs.

Treatment: Hammertoes

A hammertoe is a permanent deformity of the toe joint, in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of the toe shrink, and the toe stiffens into a hammer- or claw-like shape.

Hammertoe is most common in the second toe, but it can develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Risks include:

Lying down for long periods
Diabetes
Diseases that affect the nerves and muscles

Click the icon to see an image of a hammertoe.

Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, sold in drug stores, into the shoe. To help prevent and ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.

Surgery. Patients with severe cases of hammertome may need surgery. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes require only a single stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about 3 weeks, and then the pin is removed. One study reported that 92% of patients who had arthroscopy were still pain free after 5 years.

Treatment: Ingrown Toenails

Ingrown toenails can occur on any toe but are most common on the big toes. They usually develop when tight-fitting or narrow shoes put too much pressure on the toenail and force the nail to grow into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail. Other causes are:

Fungal infections
Injuries
Abnormalities in the structure of the foot
Repeated impact on the toenail from high-impact aerobic exercise

An ingrown toenail is a condition in which the edge of the toenail grows into the skin of the toe. The big toe is most commonly affected. Symptoms include pain, redness, and swelling around the toenail.

Caring for Toenails. Trim toenails straight across and keep them long enough so that the nail corner is not visible. If the nail is cut too short, it may grow inward. If the nail does grow inward, do not cut the nail corner at an angle. This only trains the nail to continue growing inward. When filing the nails, file straight across the nail in a single movement, lifting the file before the next stroke. Do not saw back and forth. A cuticle stick can be used to clean under the nail.

Treatments. To relieve pain from ingrown toenails, try wearing sandals or open-toed shoes. Soaking the toe for 5 minutes twice a day in a warm water solution of Domeboro or Betadine can help. People who are at increased risk for infections, such as those with diabetes, should have professional treatment.

Antibiotic ointments can treat ingrown toenails that are infected. Apply the ointment by working a wisp of cotton under the nail, especially the corners, to lift the nail up and drain the infection. The cotton will also help force the toenail to grow out correctly. Change the cotton daily, and use the antibiotic consistently.

In severe cases, more intensive treatments are needed. Surgery involves simply cutting away the sharp portion of ingrown nail, removing the nail bed, or removing a wedge of the affected tissue. One study found that orthonyxia, a newer surgical technique that implants a small metal brace into the top of the nail, is as effective as traditional surgical techniques for preventing ingrown toenails from recurring.

Nonsurgical methods can also treat ingrown toenails. One technique uses chemicals to remove the skin. Both sodium hydroxide and phenol may be used, but research shows that sodium hydroxide produces a better outcome and faster recovery than phenol. Other nonsurgical methods include using cauterization (heating), or lasers, to remove the skin.

Treatment: Forefoot Pain

Forefoot pain refers to pain and discomfort felt toward the top of the foot. The rate of forefoot pain and deformity increases with age. When a cause cannot be determined, any pain on the ball of the foot is generally referred to as metatarsalgia.

Forefoot pain may be due to:

Morton's neuroma
Sesamoiditis
Stress fractures

A neuroma usually means a benign tumor of a nerve. However, Morton’s neuroma, also called interdigital neuroma, is not actually a tumor. It is a thickening of the tissue surrounding the nerves leading to the toes. Morton’s neuroma usually develops when the bones in the third and fourth toes pinch together, compressing a nerve. It can also occur in other locations. The nerve becomes enlarged and inflamed. The inflammation causes a burning or tingling sensation and cramping in the front of the foot. Other causes of this condition include:

Tight, poorly-fitting shoes
Injury
Arthritis
Abnormal bone structure

Treatment for Neuromas. Pain from Morton's neuroma can be reduced by massaging the affected area. Roomier shoes (box-toed shoes), pads of various sorts, and cortisone injections in the painful area are also helpful. A combination of cortisone injections and shoe modifications provides better immediate relief than changes in footwear alone. Ultrasound-guided injection of alcohol might also provide relief from Morton's neuroma, research finds.

If these treatments are not effective, the enlarged area may need to be surgically removed. In one long-term study of one surgeon's experience, 85% of patients reported good to excellent satisfaction nearly 6 years after surgery. About 65% were pain free. Some numbness is common afterward, but it rarely bothers patients. Occasionally, the nerve tissue may re-grow and form another neuroma.

Sesamoiditis is an inflammation of the tendons around the small, round bones that are embedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high-impact activities, such as ballet, jogging, and aerobic exercise.

Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot are the first lines of treatment for sesamoiditis. A low-heeled shoe with a stiff sole and soft padding inside is all that is usually required. In severe cases, surgery may be necessary.

A stress fracture in the foot, also called fatigue or march fracture, usually results from a break or rupture in any of the five metatarsal bones (mostly the second or third). These fractures are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics. Women are at higher risk for stress fracture than men.

A fracture in the first metatarsal bone, which leads to the big toe, is uncommon because of the thickness of this bone. If it occurs, however, it is more serious than a fracture in any of the other metatarsal bones because it dramatically changes the pattern of normal walking and weight bearing.

Treatment for Stress Fractures. Patients should seek treatment if pain persists for 3 weeks. In a study of young athletes, treatment after that time reduced the chance that they could return to their sport. Surgery may be needed if conservative measures fail. In most cases, however, stress fractures heal by themselves if you avoid rigorous activities. Some health care providers recommend moderate exercise, particularly swimming and walking. It is best to wear low-heeled shoes with stiff soles. Occasionally, a health care provider may recommend wearing a special wooden shoe and a compressive wrap to make walking more comfortable.

Treatment: Heel Pain

The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects 2 million Americans every year. It can occur in the front, back, or bottom of the heel. Types of heel pain include:

Achilles tendinitis
Bursitis of the heel
Excess pronation
Haglund's deformity
Heel spur syndrome
Plantar fasciitis

Each type of heal pain is described in more detail below. General treatment guidelines are as follows:

The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after 8 weeks.
If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy. Surgery may be an option if other methods have failed.

Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury. This condition is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.

People at highest risk for this disorder from these activities are those with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and may bounce when they walk. A shortened tendon can be due to an inborn structural abnormality, or it can develop from regularly wearing high heels.

An inflamed or torn Achilles tendon causes intense pain and affects mobility.

Evidence is uncertain about the best way to treat either acute or chronic Achilles tendinitis. Some approaches include:

Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), may help ease pain and reduce inflammation. It is also helpful to apply ice for 20 - 30 minutes, four or five times a day. (Note: Corticosteroid injections are sometimes used, although evidence suggests they don't help very much, and they can pose a risk for rupture of the tendon.)

Gentle Stretching. Gentle calf muscle stretches may also help reduce pain and spasms. If the calf is swollen, elevate the leg. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.

Laser Therapy. Low-level laser therapy that emits energy directed at pain trigger points has helped some patients. No strong evidence supports its use to date, however.

Surgery vs. Nonsurgical Treatment. Chronic inflammation may lead to rupture of the Achilles tendon. If pain continues, the ruptured tendon will require a cast and perhaps surgery, called tendon transfer. Although some experts believe a cast without surgery is a sufficient treatment for such rupture, there is a chance the tendon may rupture again in the future, even after it heals. Some experts suggest surgery for active people and nonsurgical treatment for older people.

Surgery requires a long incision with a postoperative period of immobilization that can average 6 weeks. Complications can include a significant surgical scar, infection, and muscle atrophy, although surgery reduces pain and preserves foot function in the long term. Less invasive techniques are being tested. In one study, selected patients with ruptured tendons were hospitalized for about 5 days and fitted with special footgear (Variostabil, which continuously raised the back of the foot). The footgear was effective for most patients, and the tendon ruptured again in only 5% of cases.

Bursitis of the heel is an inflammation of the bursa, a small sack of fluid beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.

Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain, but also hip, knee, and lower back problems.

Haglund's deformity, known medically as posterior calcaneal exostosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it frequently occurs with high heels. (It can also develop in runners, however.)

Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil), will also reduce pain. Your doctor may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.

In severe cases, surgery may be necessary to remove or reduce the bony growth. According to one study, however, surgery was not effective for more than 30% of patients and, in fact, the condition worsened in 14% of patients who had surgery. A more recent study reported that surgery cured 90% of cases, but patients took 6 months to 2 years to fully recover. Experts advise patients to try all conservative measures before choosing surgery.

Plantar fasciitis is a common foot problem that accounts for 1 million office visits per year. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps serve as a shock absorber for the body.

The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel with their first steps in the morning. The pain also often spreads to the arch of the foot. The condition can be temporary, or it may become chronic if ignored. Resting can provide relief, but only temporarily.

Heel spurs are calcium deposits that can develop under the heel bone as a result of the inflammation that occurs with plantar fasciitis. Heel spurs and plantar fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.

Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports. Plantar fasciitis accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to be responsible in many cases. Other causes of this injury include poorly-fitting shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.

Treatment Goals. The three major treatment goals for plantar fasciitis are:

Reducing inflammation and pain
Reducing pressure on the heel
Restoring strength and flexibility

Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads as needed can help relieve the problem. Pain that does not subside with NSAIDs may require more intensive treatments, including leg supports and even surgery.

Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:

Put the hands on a wall and lean against them.
Place the uninjured foot on the floor in front of the injured foot.
Raise the heel of the injured foot.
Gently stretch the injured leg and foot.

With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.

Treatment. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen. NSAIDs reduce pain and disability in people with plantar fasciitis when used with other techniques, such as night splints and stretching.

Corticosteroids are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as xylocaine) may provide relief in severe cases of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current.

Several non-drug approaches can relieve pressure on the heel, including:

Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support the rest of the heel while relieving pressure on the painful spot. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics.
Night Splints. Some evidence suggests that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot stretched while the patient is sleeping. This allows the muscle to heal. One study reported that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients. Although patient compliance may be better with custom-made prescribed orthotics than with tension night splints, one study found they are equally effective in improving pain.
Elevated Heels. Some people report relief from mild symptoms with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate-to-severe condition. (Heel cups have not been proven to be very useful.)
Orthotics. For severe conditions, such as fallen arches or structural problems that cause imbalance, insoles, called orthotics, molded from a plaster cast of the patient's foot may be needed. (See "Insoles and Orthotics" section).
Extracorporeal Shock Wave Therapy (ESWT). ESWT may be used as an alternative to surgery for patients who have not responded to other treatments. The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which is believed to trigger healing of the tissues that are causing the pain. Studies show that the treatment provides a very small reduction in heel pain without side effects. It can be considered as an option for patients who haven't responded well to extensive conservative treatment.
Surgery. Surgery may be needed for some patients, typically those who have disabling heel pain that does not respond to other treatments for at least a year. A typical surgery is called instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia. A less invasive method uses a procedure called endoscopy, which requires smaller incisions. Wearing a below-the-knee walking cast after surgery for 2 weeks may reduce the need for pain relief and speed recovery time compared to the use of crutches.
Botox. Small studies show that injections of botulinum toxin (Botox), a protein used to temporarily paralyze certain muscles, reduces pain and improves patients' future ability to walk. More research is needed on this treatment.

Treatment: Flat Feet

Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over age 50, but it can occur in anyone. The following are risk factors for PTTD:

Wearing high heels for long periods of time is a particular risk for flat feet. Over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down, and the arch falls.
Some studies have indicated that the earlier a person starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on.
Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or the use of corticosteroids.

Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence. Nevertheless, whether flat feet pose any significant problems in adults is unknown. For example, one study on athletes with flat feet indicated that they had no higher risk for leg or foot injuries than did athletes with normal arches.

Treatment for Flat Feet in Children. Doctors usually can't diagnose flat feet until a child is 6 years old. Children with flat feet typically don't have symptoms, and often outgrow the condition. Children who are experiencing symptoms might need to change shoes or wear arch supports. In rare cases, minimally invasive joint insert surgery may be an option.

Treatment for Flat Feet in Adults. In general, conservative treatment for flat feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain relief and insoles or custom-made orthotics to support the foot and prevent progression.

In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis that typically lengthen the Achilles tendon and adjust tendons in the foot. One procedure uses an implant to support the arch. These procedures have potential complications. Conservative methods should be tried first.

Treatment: Abnormally High Arches

An overly-high arch (hollow foot) can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot.

Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders.

Claw toe is a deformity of the foot in which the toes are pointed down and the arch is high, making the foot appear claw-like. Claw toe can be a condition from birth or develop as a consequence of other disorders.

Treatment: Tarsal Tunnel Syndrome

Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It can cause pain anywhere along the bottom of the foot. It can occur with:

Diabetes
Back pain
Arthritis
Injury to the ankle
Abnormal blood vessels
Scar tissue that press against the nerve

Magnetic resonance imaging (MRI) and the dorsiflexion-eversion test can diagnose this syndrome.

Treatment for Tarsal Tunnel Syndrome. Specially designed shoe inserts called orthotics can relieve pain from tarsal tunnel syndrome, because they help redistribute weight and take pressure off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed, particularly if symptoms persist for more than a year, although its benefits are a matter of debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than tarsal tunnel syndrome of unknown cause. It can take months after this surgery for a person to recover and resume normal activities. Only experienced surgeons should perform tarsal tunnel syndrome surgery.

Treatment: Foot Injury

If you suspect that you have broken or fractured bones in a toe or foot, call a doctor, who will probably order x-rays. Even if you can walk, you still might have a fracture. People are often able to walk even if a foot bone has been fractured, particularly if it is a chipped bone or a toe fracture.

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat mild pain caused by muscle inflammation. Aspirin is the most common NSAID. Others include ibuprofen (Motrin, Advil, Nuprin, Rufen), ketoprofen (Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin (Tolectin). A gel containing ibuprofen can be applied to sore joints. Acetaminophen (Tylenol) is not an NSAID, and although it is a mild pain reliever, it will not reduce inflammation. It is important to note that high doses or long-term use of any NSAID can cause gastrointestinal disturbances with sometimes serious consequences, including dangerous bleeding. No one should take NSAIDs for prolonged periods of time without consulting a doctor.

The acronym RICE stands for rest, ice, compression, and elevation -- the four basic elements of immediate treatment for an injured foot.

Rest. Patients should get off injured foot as soon as possible.
Ice. This is particularly important to reduce swelling and promote recovery during the first 48 hours. Wrap a bag or towel containing ice around the injured area on a repetitive cycle of 20 minutes on, 40 minutes off.
Compression. Lightly wrap an Ace bandage around the area.
Elevation. Elevate the foot on several pillows.

Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE is helpful for remembering how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours, and gentle movement may be beneficial, but don't put pressure on a sprained joint until the pain is completely gone (one to several weeks).

Prevention

The American Podiatric Medical Association offers the following tips for preventing foot pain:

Don't ignore foot pain -- it's not normal. If the pain persists, see a doctor who specializes in podiatry.
Inspect feet regularly. Pay attention to changes in color and temperature. Look for thick or discolored nails (a sign of developing fungus), and check for cracks or cuts in the skin. Peeling or scaling on the soles of feet could indicate athlete's foot. Any growth on the foot is not considered normal.
Wash feet regularly, especially between the toes, and dry them completely.
Trim toenails straight across, but not too short. (Cutting nails in corners or on the sides increases the risk for ingrown toenails.)
Make sure shoes fit properly. Purchase new shoes later in the day when feet tend to be at their largest, and replace worn out shoes as soon as possible.
Select and wear the right shoe for specific activities (such as running shoes for running).
Alternate shoes. Don't wear the same pair of shoes every day.
Avoid walking barefoot, which increases the risk for injury and infection. At the beach or when wearing sandals, always use sunblock on your feet, as you would on the rest of your body.
Be cautious when using home remedies for foot ailments. Self-treatment can often turn a minor problem into a major one.
It is critical that people with diabetes see a podiatric physician at least once a year for a checkup. People with diabetes, poor circulation, or heart problems should not treat their own feet, including toenails, because they are more prone to infection.

Skin creams can help maintain skin softness and pliability. A pumice stone or loofah sponge can help get rid of dead skin.

Taking a warm footbath for 10 minutes two or three times a week will keep the feet relaxed and help prevent mild foot pain caused by fatigue. Adding 1/2 cup of Epsom salts increases circulation and adds other benefits. Taking footbaths only when the feet are painful is not as helpful.

In addition to wearing proper shoes and socks, walking often -- and properly -- can prevent foot injury and pain. The head should be erect, the back straight, and the arms relaxed and swinging freely at the side. Step out on the heel, move forward with the weight on the outside of the foot, and complete the step by pushing off the big toe.

Exercises specifically for the toe and feet are easy to perform and help strengthen them and keep them flexible. Helpful exercises include the following:

Raise and curl the toes 10 times, holding each position for a count of five.
Put a rubber band around both big toes and pull the feet away from each other. Count to five. Repeat 10 times.
Pick up a towel with the toes. Repeat five times.
Pump the foot up and down to stretch the calf and shin muscles. Perform for 2 or 3 minutes.

Early Development. The first year of life is important for foot development. Parents should cover their babies' feet loosely, allowing plenty of opportunity for kicking and exercise. Change the child's position frequently. Children generally start to walk at 10 - 18 months. They should not be forced to start walking early. Wearing just socks or going barefoot indoors helps the foot develop normally and strongly and allows the toes to grasp. Going barefoot outside, however, increases the risk for injury and other conditions, such as plantar warts.

Shoes. Children should wear shoes that are light and flexible, and since their feet tend to perspire, their shoes should be made of materials that breathe. Replace footwear every few months as the child's feet grow. Footwear should never be handed down. Protect children's feet if they participate in high-impact sports.

Shoes

In general, the best shoes are well cushioned and have a leather upper, stiff heel counter, and flexible area at the ball of the foot. The heel area should be strong and supportive, but not too stiff, and the front of the shoe should be flexible. New shoes should feel comfortable right away, without a breaking-in period.

Well-fitted shoes with a firm sole and soft upper are the best way to prevent many problems with the feet. They should be purchased in the afternoon or after a long walk, when the feet have swelled. There should be 1/2 inch of space between the longest toe and the tip of the shoe (remember, the longest toe is not always the big toe), and the toes should be able to wiggle upward.

Stand when being measured, and have both feet sized, buying shoes that fit whichever foot is largest. Wear the same socks as you would regularly wear with the new shoes. Women who are accustomed to wearing pointed-toe shoes may prefer the feel of tight-fitting shoes, but with wear their tastes may adjust to shoes that are less confining and properly fitted.

Ideally, the shoe should have a removable insole. Thin, hard soles may be the best choice for older people. Elderly people wearing shoes with thick inflexible soles may be unable to sense the position of their feet relative to the ground, significantly increasing the risk for falling.

High heels are the major cause of foot problems in women. Although people believe that foot binding is a problem limited to Chinese women of the past, many fashionable high heels are designed to constrict the foot by up to an inch. Women who insist on wearing high-heeled shoes should at least look for shoes with wide toe room, reinforced heels that are relatively wide, and cushioned insoles. They should also keep the amount of time they spend wearing high heels to a minimum.

The way shoes are laced can be important for preventing specific problems. Laces should always be loosened before putting shoes on. People with narrow feet should buy shoes with eyelets farther away from the tongue than people with wider feet. This makes for a tighter fit for narrower feet and a looser fit for wider feet. If, after tying the shoe, less than an inch of tongue shows, the shoes are probably too wide. Adjust tightness both at the top and bottom of the shoe. When shoes with high arches cause pain, skip eyelets when lacing them to relieve pressure.

If shoes need breaking in, place moleskin pads next to areas on the skin where friction is likely to occur. Once a blister occurs, moleskin is not effective. Change shoes during the day, and rotate between different pairs of shoes. As soon as the heels show noticeable wear, replace the shoes or their heels.

Avoid extreme variations between exercise, street, and dress shoes.

Exercise and Sports. Shoes purchased for exercise should be specifically designed for a person's preferred sport. For instance, a running shoe should especially cushion the forefoot, while tennis shoes should emphasize ankle support. Athletic socks are almost as important as shoes. Experts often recommend padded acrylic socks.

Occupational Footwear. Because a number of occupations put the feet in danger, workers in high-risk jobs should be sure their footwear is protective. For example, non-electric workers at risk for falling or rolling objects or punctures should wear shoes with steel toes and possibly other metal foot guards. Electric workers should wear footgear with no metal parts (or insulated steel toes) and rubber soles and heels. Chemical workers should wear shoes made of synthetics or rubber, not leather.


Aerobic Dancing	Sufficient cushioning to absorb shock and pressure, which should be many times greater than shock from walking. Arches that maintain side-to-side stability. Thick upper leather support. Box toe. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Cycling	Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combo hiking/cycling shoes may be sufficient for the casual biker. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance the forefoot.
Running	Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Enough traction on the sole to prevent slipping. Consider insole or orthotic with arch support for problem feet.
Tennis	Allows side-to-side sliding. Low-traction sole. Snug fitting heel with cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking	Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch anklebone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.

Insoles and Orthotics

Insoles are flat cushioned inserts that are placed inside the shoe. They are designed to reduce shock, provide support for heels and arches, and absorb moisture and odor. In general, they can be very helpful for many people.

People respond very differently to specific insoles. What may work for one person may not for another. Consider the thickness of socks when purchasing insoles to be sure they do not squeeze the toes up against the shoes. Insoles can be purchased in athletic and drug stores. Shoe stores that specialize in foot problems often sell customized, but more expensive, insoles. In general, over-the-counter insoles offer enough support for most people's foot problems. Most well-known brands of athletic shoes have built-in insoles.

Brands and Materials. There are many types of insoles available. They are composed of various materials, such as cork, leather, plastic foam, and rubber. Very effective insoles are now made from viscoelastic polymers (such as Sorbothane, Airplus, Spenco, Dr. Scholl's Massaging Gel, and others), which are gel-like materials that act both as liquids and solids.

Heel Cushions for Shortened Achilles Tendons. People who have developed short, tightened Achilles tendons (usually women who have worn high-heeled shoes for prolonged periods) should consider using heel cushions. Like insoles, heel cushions are inserted inside the shoes. They should be at least 1/8 inch thick, but not more than 1/4 inch thick.

For severe conditions, such as fallen arches or structural problems that cause imbalance, podiatrists or physicians may need to fit and prescribe orthotics, or orthoses, which are insoles molded from a plaster cast of the patient's foot. Orthotics are usually categorized as rigid, soft, or semi-rigid.

Before seeking prescription orthotics, people with less severe problems should consider testing the lower-priced, over-the-counter insoles.

Types of orthotics include:

Rigid Orthotics. Rigid orthotics are used to control motion in two major foot joints that lie directly below the ankle. They are often used to prevent excessive pronation (the turning in of the foot) and are useful for people who are very overweight or have uneven leg lengths. Some experts warn that rigid orthotics may cause sesamoiditis or benign tumors from pinched nerves.
Soft Orthotics. Soft orthotics are designed to absorb shock, improve balance, and remove pressure from painful areas. They are made from a lightweight material and are often beneficial for people with diabetes or arthritis. Soft orthotics need to be replaced periodically, and because they are bulkier than rigid orthotics, they may require larger shoes.
Semi-Rigid Orthotics. Semi-rigid orthotics are designed to provide balance, often for a specific sport. They are typically made of layers of leather and cork reinforced by silastic.

Resources

www.apma.org -- American Podiatric Medical Association
www.aofas.org -- American Orthopaedic Foot and Ankle Society
www.acfas.org -- American College of Foot and Ankle Surgeons
www.aapsm.org -- American Academy of Podiatric Sports Medicine
www.apta.org -- American Physical Therapy Association
www.diabetes.org -- American Diabetes Association
http://ndep.nih.gov/campaigns/Feet/Feet_overview.htm -- National Diabetes Education Program
www.arthritis.org -- Arthritis Foundation
www.podiatrynetwork.com -- Podiatry Network

References

Bostanci S, Kocyigit P, Gurgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatol Surg. 2007;33:680-685.

Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-23.

Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. Foot Ankle Int. 2007;28:996-999.

Gollwitzer H, Diehl P, von Korff A, Rahlfs VW, Gerdesmeyer L. Extracorporeal shock wave therapy for chronic painful heel syndrome: a prospective, double blind, randomized trial assessing the efficacy of a new electromagnetic shock wave device. J Foot Ankle Surg. 2007;46:348-357.

Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007;188:1535-1539.

Kruijff S, van Det RJ, van der Meer GT, van den Berg IC, van der Palen J, Geelkerken RH. Partial matrix excision or orthonyxia for ingrowing toenails. J Am Coll Surg. 2008;206:148-153.

Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B, Heyman ER, Borowsky P, LeMay C. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006;45:196-210.

Review Date:
12/14/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Exercise

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Chronic Conditions and Exercise:

A new study found that aerobic and resistance training significantly reduced fatigue in men undergoing radiation treatments for prostate cancer. Fatigue is a common side effect of such treatments.
Doctors at the Mayo Clinic found that exercise improves the physical and emotional well-being of patients with Alzheimer's disease. The patients exercised for as little as 60 minutes each week. Doctors noted improvements in areas ranging from depression to wandering.

Exercise and Smoking:

A 2007 review of existing studies found that moderate exercise, for as little as 5 minutes, can help combat the nicotine withdrawal symptoms people experience when they try to stop smoking.

Exercise and Aging:

A 2006 report found that older and elderly adults who exercised twice a week for 4 months significantly increased their body strength, flexibility, balance, and agility. The average age of the study participants was 83.5.

Before and After Exercising:

You should do warm-up exercises for 5 - 10 minutes at the beginning of an exercise session. Low-level aerobic exercise is the best warm-up.
To cool down, you should walk slowly until your heart rate is 10 - 15 beats above your resting heart rate. Stopping too suddenly may sharply reduce blood pressure or cause muscle cramping.
You must be careful when stretching during your warm-up to avoid injuring cold muscles.

Definitions:

Aerobic exercise: Aerobic exercise forces the heart and lungs to work harder for longer periods. It builds endurance, improves blood flow throughout the body, and increases the levels of "good" cholesterol.
Resistance Training: Resistance training works muscles against a force (usually weights). It burns fat and builds muscle.

Introduction

Everyone's goal of living a long and healthy life should include a healthy diet, regular exercise, and maintaining normal weight. The combination of inactivity and eating the wrong foods is the second most common preventable cause of death in the United States (smoking is the first).

Most research on the benefits of exercise focuses on heart protection. Studies clearly show that exercise helps the heart. In addition, new studies are reporting that even people at higher risk for heart disease may lower their risk of dying from it if they exercise.

Evidence suggests that our genes evolved to favor exercise. In other words, during prehistoric times, if a person couldn't move quickly and wasn't strong, he or she died. Those who were fit survived to reproduce and pass on these "fitter" genes. Some researchers believe that with our current inactive lifestyle, these genes produce a number of bad effects, which can lead to many chronic illnesses.

The benefits of exercise include:

Improved oxygen delivery throughout the body
Improved metabolic processes - the way the body breaks down and builds necessary substances
Improved strength and endurance
Decreased body fat
Improved movement of joints and muscles
Improved sense of well-being

In addition, exercise can help change other dangerous lifestyle habits. A 2007 review of existing studies found that moderate exercise, for as little as 5 minutes at a time, can help combat the nicotine withdrawal symptoms people experience when they try to stop smoking.

No one is too young or too old to exercise. The United States Surgeon General recommends at least 30 minutes of moderate exercise, such as brisk walking, nearly every day. However, vigorous exercise carries risks that people should discuss with a doctor. You should always check with your doctor before starting a new exercise program, especially if you have any of the following risk factors:

History of smoking
Obesity
Family history of a long-term disease
A symptom you haven’t told your doctor about
Chest pain
Shortness of breath
Heart palpitations
Blood clots
Infections
Fever
Unexplained weight loss
Foot or ankle sores that won’t heal
Joint swelling
Pain or trouble walking after a fall
Eye injury or eye surgery
Hernia
Hip surgery

Fifty percent of all people who begin a vigorous training program drop out within a year. The key to reaching and maintaining physical fitness is to find activities that are exciting, challenging, and satisfying.

Recommended Exercise Methods

A few simple rules are helpful as you develop your own routine.

Don't eat for 2 hours before vigorous exercise.
Drink plenty of fluids before, during, and after a workout.
Adjust your activity level according to the weather, and reduce it when you are fatigued or ill.
When exercising, listen to the body's warning symptoms, and consult a doctor if exercise causes chest pain, irregular heartbeat, undue fatigue, nausea, unexpected breathlessness, or light-headedness.

Heart rate is the standard guide for determining aerobic exercise intensity. It can be determined by counting one's own pulse or with the use of a heart rate monitor. To feel your own pulse, press the first two fingers of one hand gently down on the inside of the wrist or under the jaw on the right or left side of the front of the neck. You should feel a faint pounding as blood passes through the artery. Each pounding is a beat.

Click the icon to see how to take a radial pulse

Click the icon to see how to take a carotid pulse.

There are different types of heart rates.

Resting heart rate. The average heart rate for a person at rest is 60 - 80 beats per minute. It is usually lower for people who are physically fit, and often rises as you get older. You can determine your resting heart rate by counting how many times your heart beats in one minute. The best time to do this is in the morning after a good night’s sleep before you get out of bed.

Maximum heart rate. To determine your own maximum heart rate per minute subtract your age from 220. For example, if you are 45, you would calculate your maximum heart rate as follows: 220 - 45= 175.

Target heart rate. Your target rate is 50 - 75% of your maximum heart rate. You should measure your pulse off and on while your exercise to make sure you stay within this range. After about 6 months of regular exercise, you may be able to increase your target heart rate to 85% (but only if you can comfortably do so).

Certain heart medications may lower your maximum and target heart rates. Always check with your doctor before starting an exercise program.

Note: Swimmers should use a heart rate target of 75% of the maximum and then subtract 12 beats per minute. The reason for this is that swimming will not raise the heart rate quite as much as other sports because of the so-called "diving reflex," which causes the heart to slow down automatically when the body is immersed in water.


Age	Low	High
	(50% max.)	(75% max.)
20	100	150
30	95	142
40	90	135
50	85	127
60	80	120
Source: American Heart Association

VO2 Max. Serious exercisers may use a VO2 max calculation, which measures the amount of oxygen consumed during intensive, all-out exercise. The most accurate testing method uses computers, but anyone can estimate V02 without instrumentation (with an accuracy of about 95%):

After running at top pace for 15 minutes, round off the distance run to the nearest 25 meters.
Divide that number by 15.
Subtract 133.
Multiply the total by 0.172, then add 33.3.

Olympic and professional athletes train for VO2 max levels above 80. But for the average person interested in fitness, a VO2 max equaling between 50 and 80 is considered an excellent score for overall fitness.

Click the icon to see an image on exercise and heart rate.

Warming up and cooling down are important parts of every exercise routine. They help the body make the transition from rest to activity and back again, and can help prevent soreness or injury, especially in older people.

Warm-up exercises should be practiced for 5 - 10 minutes at the beginning of an exercise session. Older people need a longer period to warm up their muscles. Low-level aerobic exercise such as brisk walking, swinging the arms, or jogging in place, is the best approach.
To cool down, you should walk slowly until the heart rate is 10 - 15 beats above your resting heart rate. Stopping too suddenly can sharply reduce blood pressure, and is dangerous for older people. It may also cause muscle cramping.
Stretching may be appropriate for the cooling down period, but it must be done carefully for warming up because it can injure cold muscles. (There is no clear evidence, however, that stretching reduces muscle injuries.)

Warming up before exercise and cooling down after is just as important as the exercise itself. By properly warming up the muscles and joints with low-level aerobic movement for 5 - 10 minutes, one may avoid injury and build endurance over time. Cooling down after exercise by walking slowly, then stretching muscles, may also prevent strains and blood pressure fluctuation.

For most people, exercise may be divided into three general categories:

Aerobic or endurance
Strength or resistance
Flexibility

A balanced program should include all three. Speed training is also a major category, but generally only competitive athletes practice it.

Benefits of Aerobic Exercise. Regular aerobic exercise provides the following benefits:

Builds endurance
Keeps the heart pumping at a steady and high rate for a long time
Boosts HDL ("good") cholesterol levels
Helps control blood pressure
Strengthens the bones in the spine
Helps maintain normal weight
Improves one's sense of well-being

Types of Aerobic Exercise. Aerobic exercise is usually categorized as high or low impact. Examples of each include the following:

Low- to moderate-impact exercises: Walking, swimming, stair climbing, step classes, rowing, and cross-country skiing. Nearly anyone in reasonable health can engage in some low- to moderate-impact exercise. Brisk walking burns as many calories as jogging for the same distance and poses less risk for injury to muscle and bone.
High-impact exercises: Running, dance exercise, tennis, racquetball, squash. High-impact exercises should be performed no more than every other day, and less often for those who are overweight, elderly, out of condition, or have an injury or other medical problem that would rule out high-impact.

Click the icon to see an image of aerobic exercise.

Aerobic Regimens. As little as one hour a week of aerobic exercises is helpful, but 3 - 4 hours per week are best. Some research indicates that simply walking briskly for 3 or more hours a week reduces the risk for coronary heart disease by 65%. In general, the following guidelines are useful for most individuals:

For most healthy young adults, the best approach is a mix of low- and higher-impact exercise. Two weekly workouts will maintain fitness, but three to five sessions a week are better.
People who are out of shape or elderly should start aerobic training gradually. For example, they may start with 5 - 10 minutes of low-impact aerobic activity every other day and build toward a goal of 30 minutes per day, three to seven times a week. (For heart protection, frequency of exercises may be more important than duration.)
Swimming is an ideal exercise for many elderly and certain people with physical limitations, including pregnant women, individuals with muscle, joint, or bone problems, and those who suffer from exercise-induced asthma.
People who seek to lose weight should aim for six to seven low-impact workouts a week.

One way of gauging the optimal intensity of exercise is to aim for a "talking pace," which is enough to work up a sweat and still be able to converse with a friend without gasping for breath. As fitness increases, the "talking pace" will become faster and faster.

Shoes. All that's really necessary for a workout is a good pair of shoes that are made well and fit well. They should be broken in, but not worn down. They should support the ankle and provide cushioning for impact sports such as running or aerobic dancing. Airing out the shoes and feet after exercising reduces chances for skin conditions such as athlete's foot.

Clothing. Comfort and safety are the key words for workout clothing. For outdoor nighttime exercise, a reflective vest and light-colored clothing must be worn. Bikers, roller bladers, and equestrians should always wear safety devices such as helmets, wrist guards, and knee and elbow pads. Goggles are mandatory for indoor racquet sports. For vigorous athletic activities, such as football, ankle braces may be more effective than tape in preventing ankle injuries.

Aerobic-Exercise Equipment. Home aerobic exercise machines can be adapted to any fitness level and used day or night. Before investing in any exercise machine, however, it is wise to first test it at a gym. In addition, initial supervised training when using these machines can reduce the risk of injury that might occur with self-instruction.

Very inexpensive exercise machines tend to be flimsy and hard to adjust, but many sturdy machines are available at moderate prices. The higher-end models may utilize computers to record calories burned, speed, and mileage. While their readouts may provide motivation and gauge the intensity of a workout, however, they are not always accurate.

The following are a few observations on specific equipment:

A good floor mat is important to provide cushioning for all home exercises.
A simple jump rope improves aerobic endurance for people who are able to perform high-impact exercise. Jumping rope should be done on a floor mat plus a surface that has some give to avoid joint injury.
For burning calories, the treadmill has been ranked best, followed by stair climbers, the rowing machine, cross-country ski machine, and stationary bicycle. (Elliptical trainers, however, may be even better than treadmills for increasing heart rate, calorie expenditure, and oxygen consumption.)
Stationary bikes condition leg muscles and are fairly economical and easy to use safely. The pedals should turn smoothly, the seat height should adjust easily, and the bike's computer should be able to adjust intensity.
Stair machines also condition leg muscles. They offer very intense, low-impact workouts and may be as effective as running with less chance of injury.
Rowing and cross-country ski machines exercise both the upper and lower body.


Aerobic dancing	Sufficient cushioning to absorb shock and pressure that are many times greater than ordinary walking. Arches that maintain side-to-side stability. Thick upper leather support. Toe-box. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Cycling	Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combination hiking/cycling shoes may be sufficient for casual bikers. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance forefoot.
Running	Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Sufficient traction on sole to prevent slipping. Consider insoles or orthotics with arch support for problem feet.
Tennis	Allow side-to-side sliding. Low-traction soles. Snug fitting heels with cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking	Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch ankle bone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.

Benefits of Strength Exercise. While aerobic exercise increases endurance and helps the heart, it does not build upper body strength or tone muscles. Strength-training exercises provide the following benefits:

Build muscle strength while burning fat
Help maintain bone density
Improve digestion

It is also associated with a lower risk for heart disease, possibly because it lowers LDL (the so-called "bad") cholesterol levels.

Click the icon to see an image of cholesterol.

Strength exercise is beneficial for everyone, even people in their 90s. It is the only form of exercise that can slow and even reverse the decline in muscle mass, bone density, and strength that occurs with aging. Please note: People at risk for cardiovascular disease should not perform strength exercises without checking with a doctor.

Types of Muscle Contractions. There are three types of muscle contractions involved in strength training:

Isometric contractions do not change the length of the muscle. An example is pushing against a wall.
Concentric contractions shorten muscles. An example is the "up" phase of a bicep curl.
Eccentric contractions lengthen muscles. An example is the "down" phase as weights are lowered.

Click the icon to see an image of isometric exercise.

Strength-Training Regimens. Strength training involves intense and short-duration activities. For beginners, adding 10 - 20 minutes of modest strength training two to three times a week may be appropriate. The following are some guidelines for starting a strength regimen:

The sequence of a strength training session should begin with training large muscles and multiple joints at higher intensity and end with small muscle and single joint exercises at lower intensities.
Both shortening and lengthening muscle actions should be performed. Emphasizing the movements that lengthen muscles is of increasing interest. This approach involves slowing and increasing the duration of these "down" movements. It appears to significantly increase blood flow, and some evidence suggests it may achieve stronger muscles more quickly. It may also improve heart function compared to standard movements. Exercises that lengthen muscles may be particularly beneficial for older people and some people with chronic health problems. This type of training increases the risk for muscle soreness and injury, however, and this approach is still controversial.
Strength training involves moving specific muscles in the same pattern against a resisting force (such as a weight) for a preset number of times. This is called a repetition. Students should first choose a weight that is about half of what would require a maximum effort in one repetition. In other words, if it would take maximum effort to do a single repetition with a 10-pound dumbbell, the person would start with a five-pound dumbbell. In the beginning, most people can start with one set of 8 - 15 repetitions per muscle group with low weights. As individuals are able to perform one or two repetitions over their routine, weights can be increased by 2 - 10%.
Breathe slowly and rhythmically. Exhale as the movement begins. Inhale when returning to the starting point.
The first half of each repetition typically lasts 2 - 3 seconds. The return to the original position lasts 4 seconds.
An alternative technique called "super slow" training stretches out one repetition to a 14-second count. This method places far more stress on the muscle group, so fewer repetitions are needed. A full week of recovery is required before repeating this workout. The goal is to initiate changes in the muscles so that the body continues to burn calories after the exercise. Some people report dramatic results from this approach, but scientific proof of these claims is not available. It is a very tedious workout, and people have a hard time sticking with it. People with high blood pressure should not use this approach.
Joints should be moved rhythmically through their full range of motion during a repetition. Do not lock up the joint while exercising it.
For maximum benefit, one should allow 48 hours between workouts for full muscle recovery.

Click the icon to see the proper way to breathe during exercise.

Strength-Training Equipment. Unlike aerobic exercise, strength training almost always requires some equipment. Strength-training equipment does not, however, have to cost anything.

Any heavy object that can be held in the hand, such as a plastic bottle filled with sand or water, can serve as a weight.
Dumbbells (1 - 10 pounds) and resistance bands are inexpensive, portable, and effective.
Wearable weights help strengthen and tone the upper body.
Ankle weights strengthen and tone muscles in the lower body. Wearable ankle weights should not be worn during high-impact aerobics or jumping.
Hand grips strengthen arms and are good for relieving tension.
A pull-up bar can be mounted in a doorway for chin-ups and pull-ups.

More elaborate and expensive home equipment for working body muscles is also available, costing from $100 to over $1,000. No one should purchase or use strength-training equipment without instruction from a professional.

Benefits of Flexibility Training. Flexibility training uses stretching exercises. Many stretching exercises are particularly beneficial for the back. In general, flexibility training provides the following benefits:

Prevents cramps, stiffness, and injuries
Improves joint and muscle movement (improved range of motion)

Certain flexibility practices, such as yoga and tai chi, also involve meditation and breathing techniques that reduce stress. Such practices appear to have many health and mental benefits. They may be very suitable and highly beneficial for older people, and for patients with certain chronic diseases.

Click the icon to see an image of flexibility exercise.

Flexibility Training Regiments. Doctors recommend performing stretching exercises for 10 to 12 minutes at least three times a week. The following are some general guidelines:

When stretching, exhale and extend the muscles to the point of tension, not pain, and hold for 20 - 60 seconds. (Beginners may need to start with a 5- to 10-second stretch.)
Breathe evenly and constantly while holding the stretch.
Inhale when returning to a relaxed position. Holding your breath defeats the purpose; it causes muscle contraction and raises blood pressure.
When doing stretches that involve the back, relax the spine to keep the lower back flush with the mat, and to work only the muscles required for changing position (often these are only the abdominal muscles).

Studies continue to show that it is never too late to start exercising. A report published in the February 2006 Journal of Aging and Health found that elderly adults who exercised twice a week for four months significantly increased their body strength, flexibility, balance, and agility. The exercise program included walking and lifting weights. The average age of the study participants was 83.5. The study adds further evidence that even small improvements in physical fitness and activity can prolong life and independent living.

Still, about half of Americans over 60 describe themselves as sedentary (inactive). According to a 2004 report by the Centers for Disease Control and Prevention, approximately 12% of people aged 65 - 75 years and 10% of people aged 75 years or older meet current recommendations for strength training.

The following tips for exercising may be helpful:

Any older person should have a complete physical and medical examination, as well as professional instruction, before starting an exercise program.
Start low and go slow. For sedentary, older people, one or more of the following programs may be helpful and safe: Low-impact aerobics, gait (step) training, balance exercises, tai chi, self-paced walking, and lower legs resistance training, using elastic tubing or ankle weights. Even in the nursing home, programs aimed at improving strength, balance, gait, and flexibility have significant benefits.
Strength training assumes even more importance as one ages, because after age 30 everyone undergoes a slow process of muscular erosion. The effect can be reduced or even reversed by adding resistance training to an exercise program. As little as one day a week of resistance training improves overall strength and agility. Strength training also improves heart and blood vessel health.
Power training, which aims for the fastest rate at which a muscle or muscle group can perform work, may be particularly helpful for older women in strengthening muscles and preventing falls.
Flexibility exercises promote healthy muscle growth and help reduce the stiffness and loss of balance that accompanies aging.
Chair exercises may be performed by people who are unable to walk.
Older women are at risk for incontinence accidents during exercise. This can be reduced or prevented by performing Kegel exercises, limiting fluids (without risking dehydration), going to the bathroom frequently, and using leakage prevention pads or insertable devices.

Exercise's Effects on the Heart

Inactivity is one of the major risk factors for heart disease. However, exercise helps improve heart health, and can even reverse some heart disease risk factors.

Like all muscles, the heart becomes stronger as a result of exercise, so it can pump more blood through the body with every beat and continue working at maximum level, if need be, with less strain. The resting heart rate of those who exercise is also slower, because less effort is needed to pump blood.

A person who exercises often and vigorously has the lowest risk for heart disease, but any amount of exercise is beneficial. Studies consistently find that light-to-moderate exercise is even beneficial in people with existing heart disease. Note, however, that anyone with heart disease should seek medical advice before beginning a workout program.

The heart is a large muscular organ that pumps blood throughout the body. Valves inside the heart open and close. This controls how much blood enters or leaves the heart.

Exercise has a number of effects that benefit the heart and circulation (blood flow throughout the body). These benefits include improving cholesterol and fat levels, reducing inflammation in the arteries, assisting weight loss programs, and helping to keep blood vessels flexible and open. Studies continue to show that physical activity and avoiding high-fat foods are the two most successful means of reaching and maintaining heart-healthy levels of fitness and weight.

The American Heart Association recommends that individuals perform moderately-intense exercise for at least 30 minutes on most days of the week. This recommendation supports similar exercise guidelines issued by the Centers for Disease Control and Prevention, and the American College of Sports Medicine.

Coronary Artery Disease. People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. Experts have been attempting to define how much exercise is needed to produce heart benefits. In 2002, a well-conducted study on overweight adults confirmed previous research that reported beneficial changes in cholesterol and lipid levels, including lower LDL levels (bad cholesterol), even when people performed low amounts of moderate- or high-intensity exercise such as walking or jogging 12 miles a week. However, more intense exercise is required to significantly change cholesterol levels, notably increasing HDL (good cholesterol). An example of this kind of program would be jogging about 20 miles a week. Such benefits in the study occurred even with very modest weight loss, suggesting that overweight people who have trouble losing pounds can still achieve considerable heart benefits by exercising.

Some studies suggest that for the greatest heart protection, it is not the duration of a single exercise session that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise, which can be particularly helpful for older people.

Resistance (weight) training has also been associated with heart protection. It may offer a complementary benefit to aerobics by reducing LDL levels. Exercises that train and strengthen the chest muscles may prove to be very important for patients with angina.

Effects of Exercise on Blood Pressure. Regular exercise helps keep arteries elastic (flexible), even in older people. This, in turn, ensures good blood flow and normal blood pressure. Sedentary people have a 35% greater risk of developing high blood pressure than athletes do.

Click the icon to see the risks associated with untreated hypertension.

It should be noted that high-intensity exercise may not lower blood pressure as effectively as moderate-intensity exercise. In one study, moderate exercise (jogging 2 miles a day) controlled high blood pressure so well that more than half the patients who had been taking drugs for the condition were able to discontinue their medication. However, a small study published in 2005 suggests that moderate exercise does not have a significant impact on systolic blood pressure (the top number) in older adults. While those who exercised did have notable drops in both the top and lower (diastolic) blood pressure levels, the only statistically significant change was the decrease in the lower number.

Experts recommend at least 30 minutes of exercise on most -- if not all -- days. Studies show that yoga and tai chi, an ancient Chinese exercise involving slow, relaxing movements, may lower blood pressure almost as well as moderate-intensity aerobic exercises.

Click the icon to see an image of someone practicing yoga.

Anyone with existing high blood pressure should discuss an exercise program with their doctor. Before starting to exercise, people with moderate-to-severe high blood pressure should lower their pressure, and be able to control it with medications. Everyone, and especially people with high blood pressure, should breathe as normally as possible through each exercise. Holding the breath increases blood pressure.

Effects of Exercise on Heart Failure. Traditionally, heart failure patients have been discouraged from exercising. Now, exercise performed under medical supervision is proving to be helpful for select patients with stable heart failure.

Studies continue to report benefits from exercise training. In one study, heart failure patients as old as 91 years old increased their oxygen use significantly, after 6 months of supervised treadmill and stationary bicycle exercises.
Progressive resistance training may be particularly useful for heart failure patients, since it strengthens muscles, which commonly weaken in this disorder. Even simply performing daily handgrip exercises can improve blood flow through the arteries.

Experts warn, however, that exercise is not appropriate for all heart failure patients.

All stroke survivors should have a pre-exercise evaluation done by their doctor before starting an exercise program.

The effects of exercise on stroke are less established than those on heart disease, but most studies show benefits. The following are some examples:

According to one major analysis, men cut their risk for stroke in half if their exercise program was roughly equivalent to about an hour of brisk daily walking 5 days a week. In the same study, exercise that involved recreation was more protective against stroke than exercise routines consisting simply of walking or climbing.
A 2000 study of women also found substantial protection from stroke in brisk walking or striding (rather than casual walking).

Anyone with heart disease or risk factors for developing heart disease or stroke should seek medical advice before beginning a workout program. Patients with heart disease can nearly always exercise safely as long as they work out under medical supervision. Still, it is often difficult for a doctor to predict health problems that might arise as the result of an exercise program. At-risk individuals should be very aware of any symptoms warning of harmful complications while they exercise.

Some experts believe that anyone over 40 years old, whether or not they are at risk for heart disease, should have a complete physical examination before starting or intensifying an exercise program. Some doctors use a questionnaire for people over 40 to help determine whether they require such an examination. The questions they use are as follows:

Has any doctor previously recommended medically supervised activity because of a heart condition?
Is chest pain brought on by physical activity?
Has chest pain occurred during the previous month?
Does the person faint or fall over from dizziness?
Is bone or joint pain intensified by exercise?
Has medication been prescribed for hypertension (high blood pressure) or heart problems?
Is the person aware of or has a doctor suggested any physical reason for not exercising without medical supervision?

Those who answer "yes" to any of the above questions should have a complete medical examination before developing an exercise program.

Stress Test. A stress test helps determine the risk for a heart problem resulting from exercise. Anyone with a heart condition or history of heart disease should have a stress test before starting an exercise program. Experts currently also recommend this test before a vigorous exercise program for older persons who are sedentary, even in the absence of known or suspected heart disease. The test is expensive, however, and some experts believe that it may not be necessary for many older people with no evident health problems or risk factors.

A small percentage of heart attacks occur after heavy physical work.

High-Risk Individuals. In general, the following people should avoid intense exercise or start it only with careful monitoring:

People who have certain medical conditions: These conditions include uncontrolled diabetes, uncontrolled seizures, uncontrolled high blood pressure, a heart attack within the previous 6 months, heart failure, unstable angina, significant aortic valve disease, or aortic aneurysm.
People with moderate-to-severe hypertension: Experts generally recommend that moderate or severe high blood pressure (systolic blood pressure over 160 mm Hg or diastolic (bottom number) pressure over 100 mm Hg) should be brought to lower levels before a person starts a vigorous exercise program.
Sedentary people should be cautious. One major study found that sedentary people who throw themselves into a grueling workout significantly increase their risk of heart attack.
Episodes of exercise-related sudden death in young people are rare but of great concern. Some are preceded by fainting, which is due to a sudden and severe drop in blood pressure. It should be noted that fainting is relatively common in athletes, and is dangerous only in people with existing heart conditions. Young people with genetic or congenital (present at birth) heart disorders should avoid intensive competitive sports.
Anabolic steroids or products containing ephedra have been associated with cases of stroke, heart attack, and even death.

The risk for heart attack from exercise should be kept in perspective, however. Some form of exercise, carefully personalized, has benefits for most of the individuals mentioned above. In many cases, particularly when the only risk factors are a sedentary lifestyle and older age, exercise can often be increased over time until it is intense.

Hazardous Activities for High-Risk Individuals. The following activities may pose particular dangers for high-risk individuals:

Intense workouts (snow shoveling, slow jogging, speed walking, tennis, heavy lifting, heavy gardening) may be particularly hazardous for people with risk factors for heart disease, especially older people. They tend to stress the heart, raise blood pressure for a brief period, and may cause spasms in the arteries leading to the heart. (See image: Coronary Artery Spasm)
Some studies suggest that competitive sports, which couple intense activity with aggressive emotions, are more likely to trigger a heart attack than other forms of exercise.

Listening for Warning Signs. It should be noted that according to one study, at least 40% of young men who die suddenly during a workout have previously experienced, and ignored, warning signs of heart disease. In addition to avoiding risky activities, the best preventive tactic is simply to listen to the body and seek medical help at the first sign of symptoms during or following exercise. These symptoms include the following:

Irregular heartbeat
Shortness of breath
Chest pain

Click the icon to see an image of a coronary artery spasm.

Click the icon to see an image of stable angina.

Exercise's Effects on Diabetes

Moderate aerobic exercise can lower your risk for type 2 diabetes. An important study found that adults who worked out 2 and 1/2 hours a week cut their risk by 58%.

Exercise has positive benefits for those who have diabetes. It can lower blood sugar, improve insulin sensitivity, and strengthen the heart. Strength training, which increases muscle and reduces fat, may be particularly helpful for people with diabetes, but more evidence is needed to confirm this theory. One study reported that yoga helped patients with type 2 diabetes reduce their need for oral medications.

In 2005, researchers found that people with type 2 diabetes who walked a minimum of 3 miles every day were in better health, and had lower medical expenses, after 2 years of such exercise. Those who remained sedentary for that time period experienced a decline in their overall health and higher health care-related expenses. Study participants who worked out for an average of 38 minutes per day lowered their blood pressure, cholesterol ,and A1C levels (glucose concentration over time). These participants also had lower heart disease risk, even if they didn't lose weight. The increase in the study participants' activity equaled about 2,200 extra steps a day. The findings were reported in the journal Diabetes Care.

An earlier study found that healthy lifestyle changes may work better than the prescription medication metformin (Glucophage), when it comes to preventing metabolic syndrome. Metabolic syndrome is a combination of risk factors including abdominal obesity, insulin resistance, high triglycerides, and hypertension.

The following are precautions for all people with diabetes, whether type 1 or 2:

Because people with diabetes are at higher than average risk for heart disease, they should always check with their doctors before starting a demanding exercise program. For best and fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their doctor. For people who have been sedentary, or have other medical problems, lower-intensity exercises are recommended, using programs the patients designed with their doctors.
Strenuous strength training or high-impact exercise is not recommended for people with uncontrolled diabetes. Such exercises can strain weakened blood vessels in the eyes of patients with retinopathy (a common diabetic complication). High-impact exercise may also injure blood vessels in the feet.

Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before starting a workout program.

Glucose levels swing dramatically during exercise. People with diabetes should monitor their levels carefully before, during, and after workouts.
Patients should probably avoid exercise if glucose levels are above 300 mg/dL or under 100 mg/dL.
To avoid hypoglycemia (low blood sugar), people with diabetes should inject insulin in sites away from the muscles they use the most during exercise.
People with diabetes should drink plenty of fluids. Before exercising, they should avoid alcohol, which increases the risk of hypoglycemia.
Insulin-dependent athletes may need to decrease insulin doses, or take in more carbohydrates, prior to exercise. However, they may need to take an extra dose of insulin after exercise. Stress hormones released during exercise may increase blood glucose level (in people without diabetes, insulin is released to control this increase). People with diabetes must regularly test their blood sugar, and take any medications as instructed by their doctor.

A person with diabetes must regularly check their blood sugar (glucose) level.

Exercise's Effects on Bones and Muscles

Exercise is critical for strong muscles and bones. Muscle strength declines as people age, but studies report that when people exercise they are stronger and leaner than others in their age group.

Exercise helps kids lower their risk of chronic pain in the future. Research has shown that it helps them prevent back and neck pain. The more flexible men are as teenagers, the lower their risk of neck tension in the future, according to a study published in the February 2006 British Journal of Sports Medicine. The same report found that women who had the greatest endurance strength as teenagers had a lower risk of tension neck than those with lower teenager endurance strength. However, men with the greatest endurance strength had higher rates of knee injuries later on.

Joints are complex structures. They are designed to bear weight and move the body. Above the knee is the femur (thigh bone). Below the knee is the tibia (shin bone) and fibula. The kneecap is also called the patella. It rides on top of the lower portion of the femur and the top portion of the tibia. The muscles and ligaments connect these bones and the space between them is cushioned by fluid-filled capsules (synovia) and cartilage. When you exercise, the muscles pull on the bones, strengthening them. The range of motion of a joint represents how far it can be flexed (bent) and extended (stretched).

Joints require motion to stay healthy. Long periods of inactivity cause the arthritic joint to stiffen and the adjoining tissue to weaken. A moderate exercise program that includes low-impact aerobics, power, and strength training has benefits for osteoarthritic patients, even if exercise does not slow down the disease progression. Many patients who start an exercise program report less disability and pain. They are also better able to perform daily chores, and remain independent longer than their inactive peers. Older patients and those with medical problems should always check with their doctor before starting an exercise program.

Click the icon to see an image of osteoporosis.

The following are useful exercises for osteoarthritis patients:

Strengthening exercises builds muscle strength. Some experts encourage patients to emphasize strengthening leg muscles as a first treatment step, even before using pain relievers. They fear that patients who rely on painkilling drugs may overuse knees, which do not have strong enough muscle tissue to protect the joints from further damage. Strengthening the thigh muscles is certainly protective for those who have not developed osteoarthritis.
Range-of-motion exercises increase the amount of movement in a joint and muscle. The best examples are yoga and tai chi, which focus on flexibility, balance, and proper breathing. In one 2001 study, older adults who practiced the gentle movement, breathing, and meditation exercises of tai chi for 10 weeks reported less pain than their peers who did not learn the technique.
Low-impact aerobic workouts help stabilize and support the joints. Cycling and walking are beneficial, and swimming or exercising in water is highly recommended for people with arthritis. Patients with arthritis should avoid high-impact sports, such as jogging, tennis, and racquetball.
Some researchers are now focusing on "power" training, which involves improving the muscle's ability to move more rapidly against resisting forces, such as gravity. For example, such training helps people stand up or climb stairs more quickly. Muscle power declines more rapidly than muscle strength, and may be particularly important in older people.

Exercise is very important for slowing the progression of osteoporosis, and extremely important for reducing the risk of falling, which causes fractures. Falls are one of the leading causes of death in people over the age of 65. Exercise helps build balance and flexibility, which reduces the risk of falling.

Specific exercises may be especially helpful for reducing the risk of fractures:

Weight-bearing exercise is very beneficial for bones in people of all ages, even older people. This approach applies tension to muscle and bone, and the body responds to this stress by increasing bone density, in young adults by as much as 2 - 8% a year. Careful weight training can also be very beneficial for elderly people, particularly women. In addition to improving bone density, weight-bearing exercise reduces the risk of fractures by improving muscle strength and balance, thus helping to prevent falls.
Regular brisk long walks improve bone density and mobility. In one 2002 study, for example, older women reduced their risk of hip fracture by over 40% by working out just four hours a week.
Exercises specifically targeted to strengthen the back can be beneficial in improving posture, and may even reduce kyphosis (hunchback) in people with osteoporosis.
Low-impact exercises, particularly yoga and tai chi, which improve balance and strength, have been found to decrease the risk of falling. In one study, tai chi reduced this risk by almost half.

Click the icon to see an image of the bone-building exercise.

Note on Female Athlete Triad. Some young female athletes who exercise very intensely, and are subject to intense pressure to remain thin, are at risk for the female athlete triad. This syndrome is a combination of three disorders -- an eating disorder, loss of menstrual periods, and osteoporosis.

People who do not exercise regularly face an increased risk for low back pain, especially during times when they suddenly have to perform stressful, unfamiliar activities. These activities may include shoveling, digging, or moving heavy items. Although no definitive studies have been done to prove the relationship between lack of exercise and low back pain, sedentary living is probably a primary nonmedical cause contributing to this condition.

Lack of exercise leads to the following conditions that may threaten the back:

Muscle inflexibility can restrict the back's ability to move, rotate, and bend.
Weak stomach muscles can increase the strain on the back and can cause an abnormal tilt of the pelvis (hip bones).
Weak back muscles may increase the load on the spine and the risk of disk compression.
Obesity puts more weight on the spine and increases pressure on the vertebrae and disks. Studies report only a weak association between obesity and low back pain, however.

Benefits for Chronic Back Pain. People in with sudden and severe back pain should not exercise. Exercise plays a very beneficial role in relieving chronic back pain, however. In one study, patients with back pain lasting for an average of 18 months were assigned eight 1-hour exercise sessions over 4 weeks. They showed greater improvement in nearly every area, including reduced pain, compared to patients who did not exercise.

Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but they also alter and improve the patients' attitudes toward their disability and pain.

Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support the spine. Some exercise programs used for prevention or treatment of chronic low back pain include the following:

Low-impact Aerobic Exercises: Low-impact aerobic exercises, such as swimming, bicycling, and walking, can strengthen muscles in the abdomen and back without over-straining the back. Programs that use strengthening exercises while swimming may be a particularly beneficial approach for many patients with back pain. In one study, for example, pregnant women who engaged in a water gymnastics program had less back pain, and were able to continue working longer.
Lumbar Extension Strength Training: Exercises called lumbar extension strength training are proving to be effective. Generally, these exercises attempt to strengthen the abdomen, and improve lower back mobility, strength, and endurance. They also enhance flexibility in the hip and hamstring muscles, and in the tendons at the back of the thigh.
Yoga, Tai Chi, and Chi Kung: These exercises combine low-impact physical movements and meditation. They are based on principles of disciplining the mind to achieve a physical and mental balance, and can be very helpful in preventing recurrences of low back pain. In one study of Pilates, an exercise practice that uses yoga principles, the exercises were helpful in a woman with progressive and disabling severe low back pain resulting from early scoliosis. This approach deserves further research.
Flexibility Exercises: Whether flexibility exercises alone offer any significant benefit for chronic back pain is uncertain. One study suggested that any benefits derived from flexibility exercises are lost unless the exercise programs are sustained.
Retraining Deep Muscles: Studies are finding a link between low back pain and poor motor control of deep muscles in the back and trunk. According to these studies, contraction exercises specifically designed to retrain these muscles may be effective for patients with both acute and chronic pain.

It is important for any person who has low back pain to have an exercise program guided by professionals who understand the limitations and special needs of back pain and who can address individual health conditions. One study indicated that patients who planned their own exercise did worse than those in physical therapy or doctor-directed programs.

Hazardous Effects on the Back. Improper or excessive exercise can also cause back pain.

Exercise's Effects on the Lungs

Patients with chronic lung problems have difficulty exercising. Shortness of breath is a major limitation in most patients, but in about a third, muscle fatigue is an even greater problem. Although exercise does not improve lung function, training helps many patients with chronic lung disease by strengthening their limb muscles, thus improving endurance and reducing breathlessness.

In people who already have colds, exercise has no effect on the illness' severity or duration. People should avoid strenuous physical activity when they have fevers, muscle aches, or other symptoms of a widespread viral illnesses.

Long-term exercise may help control asthma and reduce hospitalization. One 2000 study found that aerobic exercise improves breathing capacity and function in patients with mild asthma. People with asthma who enjoy running should probably choose an indoor track, to avoid pollutants. Swimming is particularly excellent for people with asthma. Yoga practice, which uses both stretching, breathing, chest expansion, and meditation techniques may have specific benefits that include stress reduction as well as airway opening. One study reported that two thirds of patients who practiced yoga regularly were able to reduce or eliminate their asthma medications.

Exercise-Induced Asthma. About 40 - 90% of asthma cases are exercise-induced asthma (EIA), in which exercise triggers coughing, wheezing, or shortness of breath. It occurs most often in children and young adults and during intense exercise in cold dry air. EIA is triggered only by exercise. Unlike allergic asthma, there is no long-term increase in airway activity. People who only have EIA do not require long-term maintenance therapy. The warm-up and cool-down periods, which are important for any exercise regimen, may help reduce EIA events. A study of military recruits found that exercise-induced asthma attacks did not hinder their ability to perform or train, suggesting that EIA is not a reason to exclude people from physically demanding occupations.

Exercise-induced asthma is distinct from allergic asthma in that it does not produce long-term increase in airway activity. People who only experience asthma when they exercise may be able to control their symptoms with preventive measures such as warm-up and cool-down exercises.

Walking is the best exercise for people with emphysema. Patients should try to walk three to four times daily for 5 - 15 minutes each time. Devices that assist ventilation may reduce breathlessness that occurs during exercise.

Inspiratory muscle training involves exercises and devices that make inhaling (breathing in) more difficult, in order to strengthen breathing muscles. In a 2001 study, patients who took part in an inspiratory muscle training group improved their breathing, walking capacity, and quality of life. Yoga or martial arts exercises, such as tai chi, which emphasize breathing techniques and balanced movements, may be particularly beneficial for patients with emphysema.

Exercise's Effects on Weight

Exercising helps people reduce their weight, maintain weight loss, and fight obesity. Research has shown that women who regularly exercise but do not change their diet can lose significantly more weight than less active women.

Thirty minutes of moderate-intensity exercise may be adequate to maintain cardiovascular health, but it might not prevent weight gain. Recommendations published in 2003 and 2004 suggest that 45 - 60 minutes of exercise per day is necessary to promote weight loss. Children may need more activity.

Losing significant weight requires both exercise and calorie restriction. In addition, if a person exercises without dieting, any actual weight loss may be minimal because dense and heavier muscle mass replaces fat. Nonetheless, regardless of weight loss, a fit body will look more toned and be healthier.

People who exercise are more apt to stay on a diet plan. Exercise improves psychological well-being and replaces sedentary habits that usually lead to snacking. Exercise may even act as a mild appetite suppressant.

Exercising without dieting still adds health benefits. One study found that overweight but fit people have half the death rate of overweight, unfit people. Research suggests that people who have trained for a long time develop more efficient mechanisms for burning fat and are able to stay leaner.

Lifting weights builds muscle, which burns calories more efficiently than other body tissues.

The following are some suggestions and observations on exercise and weight loss:

The treadmill burns the most calories of standard aerobic machines. It may be particularly effective when used in short multiple bouts during the day. Exercise sessions as short as 10 minutes, which are done frequently (about four times a day), may be the most successful program for obese people.
The more strenuous the exercise, the longer the body continues to burn calories before returning to its resting level. This state of fast calorie burning can last for as little as a few minutes after light exercise, to as long as several hours after prolonged or heavy exercise.
Resistance (strength) training is excellent for replacing fat with muscles. It should be performed two or three times a week.
Fidgeting may be very helpful in keeping pounds off. Regular exercise is certainly the best course, but for people who must sit for hours at work, frequently shifting positions while sitting may have some benefit.
It is important to realize that as people slim down, they burn fewer calories per mile of walking or jogging. The rate of weight loss slows down, sometimes discouragingly so, after an initial dramatic head start using diet and exercise combinations. People should be aware of this trend and keep adding to their daily exercise routine.
Changes in fat and muscle distribution may differ between men and women as they exercise. Men tend to lose abdominal fat (which lowers their risk for heart disease faster than reducing general body fat). Exercise, however, does not appear to have the same effect on weight distribution in women. A study of women who practiced aerobic and strength training showed the training resulted in fat loss in the women's arms and trunk. However, they did not gain muscle tissue in those areas.

Because obesity is one of the risk factors for heart disease, anyone who is overweight must discuss their exercise program with a physician before starting.

Exercise's Effects on Other Conditions

Physical activity makes you healthier. It lowers your risk for cardiovascular disease and reduces bone loss. Physical activity also helps the body use calories more efficiently, which helps you eliminate body fat and lose weight. It also helps you maintain weight loss by increasing your metabolism and reducing your appetite.

A number of studies have indicated that regular exercise may reduce the risk of breast, colon, and possibly prostate cancers.

Studies confirm that exercise significantly reduces the risk of both colon cancer (by up to 50%) and breast cancer (by up to 30%).

A 2006 study found that, though protection from breast cancer may vary among the types of tumor, exercise offered the most marked protection from the more aggressive tumors. A second study, also done in 2006, supported this finding. Several studies also suggested that more intense exercise is more protective against breast cancer. Exercising consistently throughout life gives the best protection. Exercise not only lowers a woman's chance of getting breast cancer, it can help those who have received chemotherapy for the disease fight off fatigue.

While endurance athletes may suffer from stomach problems, low intensity exercise has a marked protective effect against colon cancer, according to studies, including the Nurses Health Study and the American Cancer Society's Cancer Prevention Study II. Furthermore, a 2006 study found that people with colon cancer who exercise reduce their risk of a recurrence.

Exercise also has a beneficial effect on people receiving treatment for prostate cancer. A new study found that aerobic and resistance training significantly reduced fatigue in men undergoing radiation treatments for prostate cancer. Fatigue is a common side effect of such treatments. In this study, 122 patients received supervised aerobic training, resistance training, or neither. At the end of 24 weeks, participants in both exercise groups noted significant improvement in their fatigue symptoms, compared to the control group. Participants in the resistance training group also lost a significant percentage of their body fat.

Endurance athletes often report stomach problems, such as bloating, diarrhea, and gas, even at rest. Experts suggest that moderate regular exercise might reduce the risk for some intestinal disorders. These disorders include ulcers, irritable bowel syndrome, indigestion, and diverticulosis. Older people who exercise moderately may have a lower risk for severe gastrointestinal bleeding.

Patients with end-stage kidney disease who exercise four to five times per week have better survival rates than those who are less active, according to researchers involved in the Dialysis Morbidity and Mortality Wave 2 study. However, the majority of study participants said that severe physical limitations prevented them from exercising so often.

Studies have shown that regular exercise, particularly walking, helps reduce one's risk for memory loss. A 2005 study found that older men who walked less than a mile daily had a 71% higher risk of dementia than those who walked more than two miles a day. A 2006 study found that people older than 65 who exercise regularly had lower risk of developing dementia, particularly Alzheimer's disease. An earlier study found that walking regularly protects women from mental decline. To date, there are no clear explanations for this apparent benefit. A preliminary study in mice suggests that physical activity changes the way brain-damaging proteins are processed in the brain, thus slowing the development of Alzheimer's disease. Aerobic exercise has been linked with improved reaction time, perception, and math skills in people of all ages.

Doctors found that exercise improves the physical and emotional well-being of patients who already have Alzheimer's disease. The patients exercised moderately for as little as 60 minutes each week. Doctors noted patients who exercised were less depressed, wandered away less, suffered fewer falls, and were placed in nursing homes later, compared to patients who did not exercise.

People with existing neurological diseases, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease, should be encouraged to exercise. Specialized exercise programs that improve mobility are particularly valuable for patients with Parkinson's disease. Patients with neurological disorders who exercise experience less stiffness, as well as reduction in, and even reversal of, muscle wasting. In addition, the psychological benefits of exercise are extremely important in managing these disorders. Exercise machines, aquatic exercises, and walking are particularly useful.

Some research has suggested that exercise may have antidepressant effects. Although there is little strong evidence that exercise can help manage depression, a number of studies have suggested benefits. Research findings include:

Just 30 minutes of brisk exercise three times a week was as effective as medication in relieving symptoms, and reducing relapse, in many patients with mild-to-moderate depression.
Over half of older women with depression that did not respond to medication improved with 10 weeks of exercise. (About a third of women who did not exercise also improved during that time.)
Studies on elderly, depressed patients report modest benefits from exercise, even in those who do not response to antidepressants. Simply participating in a group activity may help improve mood.
Teenagers who are active in sports have a greater sense of well-being than their sedentary peers. The more vigorously they exercise, the better their emotional health.
Physical inactivity is strongly linked to depression in children 8 - 12 years of age.

Specific exercises may be particularly beneficial:

Aerobics. Either brief periods of intense training or prolonged aerobic workouts can raise levels of certain chemicals in the brain. These chemicals -- which include endorphins, adrenaline, serotonin, and dopamine -- produce the so-called runner's high. Weight loss and increased muscle tone can boost self-esteem.

Yoga. Yoga practice, which involves rhythmic stretching movements and breathing, has been found to positively affect mood. It may have clinical potential as a technique for improving and stabilizing mood. A study comparing yoga to aerobic exercise found that men have significantly lower levels of tension, fatigue, and anger after yoga, compared with levels after swimming. Yoga and swimming tended to produce equal benefits in women.

Click the icon to see an image of the benefits of yoga.

Moderate exercise in healthy pregnant women does not increase the risk for miscarriage, preterm labor, or rupture of the membrane. Not exercising increases the risk for complications, including low-birth weight babies. Exercising increases the fetal heart rate, which in turn protects the baby.

Healthy women with normal pregnancies should exercise at least three times a week, being careful to warm up, cool down, and drink plenty of liquids. Many prenatal calisthenics programs are available.

The following are specific exercises that may benefit the pregnant woman:

Swimming and water aerobics may be the best option for most pregnant women. Swimming has special benefits for those with fluid buildup. Water exercises involve no impact, overheating is unlikely, and swimming face down promotes optimum blood flow to the uterus.
Performing yoga exercises under the guidance of informed instructors can be very helpful.
Walking is also beneficial.

To strengthen pelvic muscles, women should perform Kegel exercises at least six times a day. This involves contracting the muscles around the vagina and urethra for three seconds 12 - 15 times in a row.

Experts generally recommend the following precautions for pregnant women who exercise:

Fit women who have exercised regularly before pregnancy may work out intensely as long as the doctor approves and no discomfort occurs.
As a rule for previously sedentary, low-risk expectant mothers, the pulse rate should not exceed 70 - 75% of the maximum heart rate, or more than 150 beats per minute. Any sedentary expectant mother should check with her doctor before starting an exercise program.
According to one study, vigorous exercise may improve the chances for a timely delivery. All pregnant women, however, should avoid high-impact, jerky, and jarring exercises, such as aerobic dancing, which can weaken the pelvic floor muscles that support the uterus.
During exercise, women should monitor their temperature to avoid overheating, a side effect that can damage the fetus. (Pregnant women should also not use hot tubs or steam baths, which can cause fetal damage and miscarriage.)

Note: Strenuous exercise may affect the flavor of breast milk for a short time afterward. Nursing mothers who engage in such activity might want to wait about an hour after exercising before they feed their infant.

Complications

Exercise may lead to injury if not done properly. Always exercise with care.

Competitive running or high-impact aerobics pose a high risk of a number of injuries to the bones and muscle. The effect of high-impact exercise on the back is not entirely clear. Some research suggests that over time, high-impact exercise may increase the risk for degenerative disk disease. A survey of people who played tennis, however, found no increased risk for low back pain or sciatica.

High-impact exercise can also cause dizziness, ringing in the ear, motion sickness, or loss of high-frequency hearing.

Some research further suggests that in people unused to exercise, intense activity increases production of harmful particles in the body called free radicals. These unstable oxygen particles injure muscle tissue. Muscle pain in this case does not occur until 24 - 48 hours after exercise.

Some people have a higher than average risk for injury:

About half of people at any age who participate in competitive running or high-impact aerobics experience minor injuries at least once a year. Young, intensely competitive athletes may be at risk for permanent injury. Studies are mixed over whether intensive high-impact sports in younger people cause long-term degenerative joint disease.
As the number of older people who start exercising increases, there has also been an increase in injuries for this age group. Between 1990 and 1996, injuries from active sports increased by 54% in people age 65 and older.
Women are far more likely than men to suffer knee injuries.
Urinary incontinence affects many female athletes who engage in high-impact exercise.
Tennis players are at high risk for injuries from repetitive force on the shoulder joint.

Preventing High-Impact Injuries. The following may be helpful for preventing injury:

Wear shock-absorbing footwear with weight-dampening inserts.
Combine weight lifting with jumping exercises. This may prevent injury by strengthening hamstrings and improving coordination.
Vary training and alternate easy and harder workouts.
Be careful to warm up, cool down, and stretch. Flexibility is the key to preventing many muscle strains.
Take days off now and then. The risk of injury increases when athletes train more than five times a week.

Because of the association between high-impact exercises and oxidation, some experts suggest eating foods rich in antioxidants, such as vitamins A, C, and E. Such foods, which may protect against damage from free radicals, include many fresh fruits and vegetables.

Treating Minor Injuries. Most mild or moderate injuries respond well to a simple, four-step treatment: rest, ice, compression, and elevation (RICE). This combination works well for both spot injuries and chronic problems. Ice packs, which reduce inflammation and pain, can help new injuries, and can be useful for the first few hours after a chronically injured area is exercised. How much or how long to compress the injury is unclear.

Evidence suggests that early movement is helpful, although taping or bracing in people with a recurrent ankle sprain is known to be protective. It may not be helpful in those without a previous ankle injury.

Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE can help you remember how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours. Gentle movement may help, but pressure should not be put on a sprained joint until pain is completely gone. This can take up to a few weeks.

Heat, ultrasound, whirlpool, and massage may speed healing if applied a day or two after the initial injury or for warm-up before another workout session.

Some young female athletes who exercise very intensely, and are subject to intense pressure to remain thin, are at risk for a syndrome known as the female athlete triad. This combination of symptoms includes loss of menstruation, eating disorders, and osteoporosis. Eating disorders among young female athletes are estimated at 15 - 62%. Women at higher risk include ballet dancers, gymnasts, and divers. Continued intense exercise causes a stress response in which estrogen (the primary female hormone) is lost. Estrogen loss can lead to infertility and osteoporosis. Iron loss and anemia may also be a problem in women who exercise frequently, even at moderate intensity. A doctor should be consulted for any of these concerns.

Incorrect movements can literally cause mechanical problems in the muscles. These problems are usually the result of improper exercise instruction, and lack of attention. A single jerky golf swing, or the incorrect use of exercise equipment (especially free weights, nautilus, and rowing machines), can cause serious back injuries.

Between 30 - 70% of cyclists experience low back pain. Pain may be improved by adjusting the angle of the bicycle seat.

Everyone should drink lots of fluid during intense exercise. Thirst is often a poor indicator of dehydration in people who exercise, particularly older people. During a tough workout in a hot environment, the body can lose two liters of fluid per hour through sweat.

Anyone who exercises intensely should take the following precautions:

Drink 6 - 8 ounces of fluid about 15 minutes before a workout, and then pause regularly during exercise to drink more.
Water is the best choice for replenishing body fluids. Glucose-sodium-potassium solutions, the so-called "sports drinks," which promise instant energy, appear to be no better than water at improving endurance during prolonged intense running.
Caffeinated beverages like coffee and soft drinks give short bursts of energy, but can actually cause fluid loss. Caffeine before a workout has been shown to temporarily raise blood pressure, and reduces blood flow to inactive limbs.

Contrary to popular belief, drinking fluids will not cause cramps. Drinking enough, in fact, helps prevent the painful involuntary muscle spasms that sometimes occur during exercise.

Overheating, or hyperthermia, can be a problem with hard exercise, or when working out in hot weather. Overheating can cause mild to life-threatening conditions. Heat exhaustion, a moderate form of hyperthermia, is characterized by the following symptoms:

Lightheadedness, nausea, headache, hyperventilation, fatigue, and loss of concentration
A high temperature (above 103° F), possibly accompanied by complaints of chills and clammy skin

Individuals should rest in a cool, dry place, drink plenty of fluids, and bring down their body temperature with ice packs pressed against the skin.

Heatstroke. Heatstroke is the most dangerous complication of hyperthermia. The victim may suddenly stop sweating, after which symptoms such as altered consciousness, seizures, and even coma may quickly follow. Heat stroke is a medical emergency and requires immediate cooling of the victim in an ice-water bath or with ice packs. One study suggests that risk for serious complications from exercising in high temperatures may persist as late as the following day, even if the weather has cooled down.

Click the icon to see an image of the dangers of heatstroke.

Precautions are also necessary in cold weather. When exercising in winter dress in layers, including gloves and socks, which create insulated air pockets that trap heat. In cold weather, wear shoes with less ventilation than those worn in the summer. Fingers, toes, ears, and nose are most susceptible to frostbite. Frostbite progresses from stinging or aching to numbness. Fingers and toes may become white. Soaking the hands and feet in warm water can help, but only once there is no risk of refreezing, since a second bout of frostbite after thawing can quicken tissue damage.

Hypothermia can be life-threatening and can occur even after long exposure to temperatures that are above freezing. The condition is characterized by extreme fatigue, mental confusion, apathy, and a lack of coordination. The victim should be warmed as soon as possible with blankets, body heat, and warm fluids.

Motivation

Motivation, or a lack thereof, is one reason many people stop exercising. Here are some tips for avoiding burnout:

Think of exercise as a menu rather than a diet. Choose a number of different physical activities that are personally enjoyable such as sports, dancing, or biking. Although experts say you should get 30 minutes of aerobic exercises at least five times a week, those times can be divided into shorter periods -- such as 10 minute sessions. In addition, people can achieve health benefits from other exercise programs, including weight training, yoga, or tai chi.
Stick to a prepared schedule and record progress.
Develop an interest or hobby that requires physical activity.
Adopt simple routines such as climbing the stairs instead of taking the elevator, walking instead of driving to the local newsstand, or canoeing instead of zooming along in a powerboat.
Try cross training (regularly switching from one type of exercise to another). Studies suggest it is more beneficial than focusing only on one form of exercise.
Exercise with friends.
Join a gym or take classes. Many affordable programs are available.
For those who can afford them, personal trainers can be very helpful and are available in many gyms and exercise clubs. Personal trainers without any connection to a well-reputed gym or fitness club should be certified by a major fitness organization, such as the Aerobics and Fitness Association of America (AFAA) or the American Council on Exercise.
Exercise videos may also be helpful, but people should be sure they are suited to their individual age and health needs, and bear the seal of the AFAA.
Consider getting a dog. A study in the February 2006 American Journal of Preventive Medicine found that dog owners in Canada walk almost twice as much as those who don’t own a dog. Regular walking is a good way to improve health.

Differences in Motivation Between Men and Women. Motivation factors may differ by gender, and women appear to have a harder time. In one study, weight loss was the greatest motivator to exercise for women, and muscle tone was the primary motivator for men. Unfortunately, effects on appearances may take a long time to show, discouraging people from continuing an exercise program even though their health is improving.

Overweight among children and adolescents has now become an epidemic in the United States. Experts say that children should be vigorously active for at least 20 - 60 minutes 3 - 5 days a week. Parents and schools must be imaginative and rigorous in encouraging children to exercise.

Role of Parents. Parents must make conscious efforts to limit sedentary activities, and to encourage physical ones for their children. This includes monitoring the time children spend on the computer, in front of the TV, or playing video games. Parents should suggest different forms of entertainment. Even children who aren't interested in joining a Little League team may enjoy a round of catch with their parents, walking in the park, or swimming in a local lake.

Role of Schools. Early school physical education programs can make a significant difference and the earlier these routines are learned, the more likely they will be carried forth into a healthy adulthood. Schools should emphasize team cooperation or individual improvement and self-mastery. Studies have shown that people tend to give up more quickly and feel less competent if their perceptions of success are based only on comparison to their peers.

People mature at different rates, and there seems to be a genetic component to coordination, strength, speed, and one's response to resistance exercise. Nonetheless, everyone should strive to be as fit as they possibly can, given their strengths and limitations.

The decision to adopt a healthier behavior -- whether it's more exercise, weight loss, or quitting smoking -- is not as simple as just deciding to do it. Behavior change expert James Prochaska and his colleagues outlined a theory, which has been supported by numerous studies, showing that people cycle through a variety of stages before a new behavior is successfully adopted over the long term. It may help you to understand how this works. As you read the description of each stage -- specifically as it relates to exercise -- you may find yourself nodding and saying to yourself, "Yes, that's me!"

Stage 1: Pre-Contemplation. People at this stage have no plans or desire to exercise. They aren't even considering exercising. They are generally unaware of the specific benefits that exercise can bring -- exercise may seem more like a hassle than something worth doing. Or, they may simply have "failed" in the past and have given up.

There's no point in talking about how to start an exercise program if you are at this stage. Instead, it is important to think about how exercise might be good for you personally -- by helping you to lose weight, feel better, have more confidence, live longer, sleep better, or reduce your stress levels. The benefits must be identified before a person will consider exercise.

If you are at this stage, a good activity is to ask four friends or family members why they exercise. Their answers may show you some real-life benefits, and inspire enough interest to compel you to take the next step.

Stage 2: Contemplation. A person at this stage is thinking, "I think I should probably exercise, but I need help getting started." People at this stage know that exercise is good for them, but it seems like a daunting task or they don't think they can pull it off. Some may have tried and "failed" in the past, but they are still receptive to another go-round.

It's important for people at this stage to consider some of the truths and falsehoods of exercise. For example, it is helpful to know that there are many forms of physical activity to select from, and that you can do your exercising in small chunks. It is not true that exercise has to be painful, or that you either succeed or fail. There is no such thing as "failure" -- people become more or less active at different stages of their lives, and it is never too late to get moving again. And people at this stage should find assurance that an exercise plan can be very simple.

If you are at this stage, a good activity is to write down all the things that you believe make exercise difficult -- and to learn strategies for overcoming or side-stepping those hurdles. People at this stage might benefit from making a pledge, contract, or other commitment that they are going to get more active in the near future. The goal is to get un-stuck by identifying the roadblocks and the ways to overcome these roadblocks. The final goal at this stage is to make a commitment.

Stage 3: Preparation. These folks are primed and motivated. They are ready to give exercise a try. The goal of this stage is to create a specific action plan that takes all factors into account, so that the "launch" is successful. People at this stage need to know how much they should be exercising, their target heart rate, and the types of exercises. They should explore the different kinds of exercises and decide which ones to try.

At this stage, people will evaluate exercise machines and health plans, if that interests them, pick the proper clothing or accessories, and consult a doctor if necessary. They also need to think about how they are going to fit their exercise plans into their daily and weekly schedule.

If you are at this stage, you should also consider some backup plans -- what to do if it rains, or if you don't feel like exercising. That way you are prepared to overcome that hurdle when you encounter it. You should be aware of what to expect realistically at the beginning -- for example, be aware that weight loss takes time, but health benefits begin immediately.

Stage 4: Action! People at this stage have just started exercising. This stage is where the biggest behavior change occurs -- these people have started to exercise but it is not yet a long-term, ingrained habit. This stage requires significant commitment and energy.

If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. Give yourself notes and reminders to exercise. Having a friend to exercise with can be very helpful as you get through this stage. You want to build and maintain momentum, because exercising gets easier once it is a habit!

Stage 5: Maintenance. The people at this stage have been exercising for at least 6 months. At this point, exercising has started to become a habit. The goal here is to prevent relapse. If you are at this stage, identify ways that you can fine-tune your program. Continue to identify roadblocks and improve your backup plans. Think about what you have found most enjoyable about exercising.

What benefits have you gained? Keep reminding yourself of these perks. If giving yourself a challenge was part of your initial motivation, set new goals and find new challenges. If you risk getting bored with your routine, find ways to vary it. Or maybe you have found a comfortable routine that you enjoy -- if it's working, great! There is no need to change it. You might want to read or learn more about your method of exercising, and develop a deeper level of understanding about it. Soon you'll be a pro!

One point about this theory is that people do not proceed from one stage to another in a simple, step-by-step fashion. They actually cycle or spiral back and forth, so that they may move from stage 1 to 2 to 3, and then back to 2 again. They may stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal -- if you tried exercising in the past and didn't stick with it, don't consider yourself a failure. Just know that it's time to try again!

Resources

http://fitness.gov -- The President's Council on Physical Fitness and Sports
www.ncppa.org --National Coalition for Promoting Physical Activity
www.acefitness.org --American Council on Exercise
www.arthritis.org --The Arthritis Foundation offers tips on exercising with arthritis
www.justmove.org -- Just Move (American Heart Association)

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Tehard B, Friedenreich CM, Oppert JM, et al. Effect of physical activity on women at increased risk of breast cancer: results from the E3N cohort study. Cancer Epidemiol Biomarkers Prev. 2006 Jan;15(1):57-64.

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Larson EB, Wang L, Bowen JD et al. Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Ann Intern Med. 2006 Jan 17;144(2):73-81.

Meyerhardt JA, Heseltine D, Niedzwiecki D, et al. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol. 2006 Aug 1;24(22):3535-41.

Slattery ML. Physical activity and colorectal cancer. Sports Med. 2004;34(4):239-52.

Peters HP, De Vries WR, Vanberge-Henegouwen GP et al. Potential benefits and hazards of physical activity and exercise on the gastrointestinal tract. Gut. 2001 Mar;48(3):435-9.

Abbott, RD, White, LR, G. Ross, W, et al. Walking and Dementia in Physically Capable Elderly Men. JAMA. 2004;292:1447-1453

Calton BA, Lacey JV Jr, Schatzkin A, Schairer C, Colbert LH, Albanes D, Leitzmann MF. Physical activity and the risk of colon cancer among women: A prospective cohort study (United States). Int J Cancer. 2006 Feb 17; [Epub ahead of print]

Di Loreto C, Fanelli C, Lucidi P, et al. Make your diabetic patients walk: long-term impact of different amounts of physical activity on type 2 diabetes. Diabetes Care. 2005 Jun;28(6):1295-302.

Mikkelsson LO, Nupponen H, Kaprio J, Kautiainen H, Mikkelsson M, Kujala UM. Adolescent flexibility, endurance strength, and physical activity as predictors of adult tension neck, low back pain, and knee injury: A 25 year follow up study. Br J Sports Med. 2006 Feb;40(2):107-13.

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Review Date:
4/30/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Scoliosis

FitSugar — Wed, 08 Oct 2008 17:35:13 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Prognosis
Symptoms
Diagnosis
Treatment
Managing Scoliosis
Braces
Surgery
Treatment for Adult Scolios...
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Diagnosing Scoliosis

Scoliosis is diagnosed typically in children 10 - 15 years of age. However, only about 1% of cases actually require treatment. There is a large female preponderance for larger curves that do require treatment.

Defining Scoliosis

Nonstructural scoliosis is a simple side-to-side curve of the spine. Structural scoliosis adds to that simple curve a rotation of the vertebrae, resulting in a twisting of the spine.

Causes

In about 80% of scoliosis cases, the cause is unknown (idiopathic scoliosis). Research has not been able to identify any genetic abnormality that would make a person susceptible to developing scoliosis.

Treatment with Bracing

Bracing has long been the standard treatment to prevent progression of the curvature of scoliosis. However, patient compliance has been a problem, especially for younger patients. Newer braces are now more comfortable and can be worn discretely under the clothing, thus improving patient compliance and treatment results.

Introduction

Scoliosis is the abnormal curvature of the spine. While the normal spine has gentle natural curves that round the shoulders and make the lower back curve inward, scoliosis typically involves a three-dimensional deformity of the spinal column and rib cage. To varying degrees, the spine curves from side-to-side, and some of the spinal bones may rotate slightly, making the hips or shoulders appear uneven. It may develop in the following way:

As a single primary side-to-side curve (resembling the letter C), or
As two curves (a primary curve along with a compensating secondary curve that forms an S shape).

Scoliosis most commonly develops in the area between the upper back (the thoracic area) and lower back (lumbar area). It may also occur only in the upper or lower back. The doctor attempts to define scoliosis by the following characteristics:

The shape of the curve
Its location
Its direction
Its magnitude
Its causes, if possible

Click the icon to see an image of scoliosis.

The severity of scoliosis is determined by the extent of the spinal curvature and the angle of the trunk rotation (ATR) and is usually measured in degrees. Curves of less than 20 degrees are considered mild and account for 80% of scoliosis cases. Curves that progress beyond 20% require medical attention. Such attention, however, usually involves periodic monitoring to make sure the condition is not becoming worse.

Scoliosis affects about 2 - 3% of the population (about 6 million people in the United States). It can occur in adults but is more commonly diagnosed for the first time in children aged 10 - 15 years. About 10% of the adolescent population has some degree of scoliosis, but less than 1% develops scoliosis that requires treatment. The condition also tends to run in families. Among persons with relatives that have scoliosis, about 20% develop the condition.

Among adults, previous reports have indicated a prevalence of scoliosis of up to 32%. But a recent study of 75 healthy adults aged 60 years and older with no known history of scoliosis or prior spine surgery suggested a rate of 68%. However, scoliosis was not linked to physical or social impairment in this population.

Scoliosis is often categorized by the shape of the curve, usually as either structural or nonstructural.

Structural scoliosis. In addition to the spine curving from side to side, the vertebrae rotate, twisting the spine. As it twists, one side of the rib cage is pushed outward so that the spaces between the ribs widen and the shoulder blade protrudes (producing the rib-cage deformity, or hump). The other half of the rib cage is twisted inward, compressing the ribs.
Nonstructural scoliosis. The curve does not twist but is a simple side-to-side curve.

Other abnormalities of the spine that may occur alone or in combination with scoliosis include hyperkyphosis (an abnormal exaggeration in the backward rounding of the upper spine) and hyperlordosis (an exaggerated forward curving of the lower spine, also called swayback).

Click the icon to see an image of kyphosis.

The location of a structural curve is defined by the location of the apical vertebra. This is bone at the highest point (the apex) in the spinal hump. This particular vertebra also undergoes the most severe rotation during the disease process.

The direction of the curve in structural scoliosis is determined by whether the convex (rounded) side of the curve bends to the right or left. For example, a doctor will diagnose a patient as having right thoracic scoliosis if the apical vertebra is in the thoracic (upper back) region of the spine, and the curve bends to the right.

The magnitude of the curve is determined by taking measurements of the length and angle of the curve on an x-ray view.

Vertebrae. The spine is a column of small bones, or vertebrae, that support the entire upper body. The column is grouped into three sections of vertebrae:

Cervical (C) vertebrae are the 7 spinal bones that support the neck.
Thoracic (T) vertebrae are the 12 spinal bones that connect to the rib cage.
Lumbar (L) vertebrae are the 5 lowest and largest bones of the spinal column. Most of the body's weight and stress falls on the lumbar vertebrae.

Each vertebra can be designated by using a letter and number; the letter reflects the region (C=cervical, T=thoracic, and L=lumbar), and the number signifies its location within that region. For example, C4 is the fourth bone down in the cervical region, and T8 is the eighth thoracic vertebra.

Below the lumbar region is the sacrum, a shield-shaped bony structure that connects with the pelvis at the sacroiliac joints. At the end of the sacrum are 2 - 4 tiny, partially fused vertebrae known as the coccyx or "tail bone."

The Spinal Column and its Curves. Altogether, the vertebrae form the spinal column. In the upper trunk the column normally has a gentle outward curve (kyphosis) while the lower back has a reverse inward curve (lordosis).

The Disks. Vertebrae in the spinal column are separated from each other by small cushions of cartilage known as intervertebral disks. Inside each disk is a jelly-like substance called the nucleus pulposus, which is surrounded by a tough, fibrous ring called the annulus fibrosis. The disk is 80% water. This structure makes the disk both elastic and strong. The disks have no blood supply of their own, relying instead on nearby blood vessels to keep them nourished.

Processes. Each vertebra in the spine has a number of bony projections, known as processes. The spinal and transverse processes attach to the muscles in the back and act like little levers, allowing the spine to twist or bend. The particular processes form the joints between the vertebrae themselves, meeting together and interlocking at the zygapophysial joints (more commonly known as facet or z joints).

Spinal Canal. Each vertebra and its processes surround and protect an arch-shaped central opening. These arches, aligned to run down the spine, form the spinal canal, which encloses the spinal cord, the central trunk of nerves that connects the brain with the rest of the body.

Click the icon to see an image of the spine.

Click the icon to see an image of the sacrum.

Click the icon to see an image of the curves of the spine.

Click the icon to see an image of an intervertebral disk.

Click the icon to see an image of the spinal canal.

Causes

In 80% of patients, the cause of scoliosis is unknown. Such cases are called idiopathic scoliosis. (Idiopathic means without a known cause.) Idiopathic scoliosis may be due to multiple, poorly understood inherited factors, most likely from the mother's side. However, the severity often varies widely among family members who have the condition, suggesting that other factors must be present.

Researchers have not been able to identify the specific genetic abnormalities that make a young person susceptible to spinal distortion. Inherited physical abnormalities, problems in coordination, abnormalities in the central nervous system, and other inherited factors may play some role either alone or in combination with other conditions to produce scoliosis.

Physical Abnormalities. Researchers are investigating possible physical abnormalities that may cause imbalances in bones or muscles that would lead to scoliosis. Among them are the following:

Imbalances in Muscles around the Vertebrae. Some research suggests that imbalances in the muscles around the vertebrae may make children susceptible to spinal distortions as they grow.
High Arches. One study showed a higher incidence of abnormally high arches in the feet in people with idiopathic scoliosis, suggesting that altered balance may be a factor in certain cases.

Problems in Coordination. Some experts are looking at inherited defects in perception or coordination that may cause asymmetrical growth in the spine of some children with scoliosis.

Genetic Abnormalities in the Central Nervous System. Genetic defects that cause altered processing in the brain may play a role in producing abnormalities in the growing spine. For example, research has implicated low levels of melatonin, a hormone secreted in the pineal gland in brain. Melatonin is involved with sleep and growth. Researchers speculate that genetic factors that cause reduced blood levels of melatonin may adversely affect muscle tone and development during sleep, perhaps contributing to scoliosis.

Other Biologic Factors. Several other biologic factors are being investigated for some contribution to scoliosis:

Abnormalities in collagen, the critical structural protein found in muscles and bones. Enzymes known as matrix metalloproteinases are involved in the repair and remodeling of collagen. Researchers have found high levels of the enzymes in the disks of patients with scoliosis, which suggests that the enzymes may contribute to curve progression. Elevated levels of the enzymes can cause abnormalities in components in the spinal disks, contributing to disk degeneration.
A possible defective gene responsible for production of fibrillin, an important component of connective tissue, which makes up bones and muscles.
Abnormalities in a protein called platelet calmodulin that binds to calcium. This protein acts like a tiny muscle and pulls clots together. Measuring levels of this protein may eventually help predict whether scoliosis will worsen.

Congenital scoliosis is caused by inborn spinal deformities that may result in the development of absent or fused vertebrae. Kidney problems, particularly having only one kidney, often coincide with congenital scoliosis. The condition usually becomes evident at either age 2 or between ages 8 and 13 as the spine begins to grow more quickly, putting additional stress on the abnormal vertebrae. It is essential to diagnose and monitor such curvatures as early as possible, since they can progress quickly. Early surgical treatment -- before age 5 -- may be important in many of these patients to prevent serious complications.

Adult scoliosis has two primary causes:

Progression of childhood scoliosis.
Degenerative lumbar scoliosis. Degenerative lumbar scoliosis is a condition that typically develops after age 50. With this condition, the lower spine is affected, usually due to disk degeneration. Osteoporosis, a serious problem in many older adults, is not a risk factor for new-onset scoliosis, but it can be a contributing factor. In most cases, however, it is not known why scoliosis occurs in adults.

Scoliosis may be a result of various conditions that affect bones and muscles associated with the spinal column. They include the following:

Muscle paralysis.
Muscle deterioration from diseases such as muscular dystrophy, polio, or cerebral palsy.
Injury to the spinal cord.
Tumors, growths, or other small abnormalities on the spinal column. For example, syringomyelia, a disorder in which cysts form along the spine, can cause scoliosis. These spinal abnormalities may play a larger role in causing some cases of scoliosis than previously thought.
Familial dysautonomia, a rare disorder in Jewish children of Ashkenazi descent. (Only about 500 cases have been reported.)
Stress fractures and hormonal abnormalities that affect bone growth in young, competitive athletes.
Birth defects, including spina bifida (an open spinal cord) and myelomeningocele (a hernia of the central nervous system).
Turner syndrome, a genetic disease in females that affects physical and reproductive development.
Other diseases that can cause scoliosis are Marfan syndrome, Aicardi syndrome, Friedreich ataxia, Albers-Schonberg disease, rheumatoid arthritis, Cushing syndrome, and osteogenesis imperfecta.

Spina bifida is a congenital disorder (birth defect) in which the backbone and spinal canal do not close before birth. In severe cases, this can result in the spinal cord and its covering membranes protruding out of an affected infant's back. Spina bifida may also be nearly inconsequential, or may be repairable through surgery.

Nonstructural scoliosis is usually not a serious problem, since the curve is side to side. It can develop from a number of physical problems, including the following:

Unequal leg length. Injury, a shortened Achilles tendon, or other structural in-born problems can cause this very common condition. Unequal leg length rarely causes any problems and in most cases requires no treatment other than a lift in one of the shoes to equalize the length.
Muscle spasms.

Risk Factors

Risk Factors for Initial Scoliosis. Idiopathic scoliosis, the most common form, occurs most often during the growth spurt right before and during adolescence. (Between 12 - 21% of idiopathic cases occur in children ages 3 - 10 years, and less than 1% in infants.) Mild curvature (under 20 degrees) occurs about equally in girls and boys, but curve progression is 10 times more likely to occur in girls. Being taller than average at earlier ages may put some girls at risk, but other factors must be present to produce scoliosis. A risk factor that affects females is a delayed onset of menstruation, which can prolong the growth spurt period, thus increasing the possibility for the development of scoliosis.

Risk Factors for Curvature Progression. Once scoliosis is diagnosed, it is very difficult to predict who is at highest risk for curve progression. About 2 - 4% of all adolescents develop curvature of 10 degrees or more, but only about 0.3 - 0.5% of teenagers have curves greater than 20 degrees, which requires some medical attention.

People with certain medical conditions that affect the joints and muscles are at higher risk for scoliosis. These conditions include rheumatoid arthritis, muscular dystrophy, polio, and cerebral palsy. Children who receive organ transplants (kidney, liver, heart) are also at increased risk.

In one study, idiopathic scoliosis occurred in about 5% of close family members of children with the condition.

Scoliosis may be evident in young athletes, with a prevalence of 2 - 24%. The highest rates are observed among dancers, gymnasts, and swimmers. The scoliosis may have been due in part to loosening of the joints, delay in puberty onset (which can lead to weakened bones), and stresses on the growing spine. There have also been other isolated reports of a higher risk for scoliosis in young athletes who engage vigorously in sports that put an uneven load on the spine. These include figure skating, dance, tennis, skiing, and javelin throwing, among other sports. In most cases, the scoliosis is minor, and everyday sports do not lead to scoliosis. Exercise has many benefits for people both young and old and may even help patients with scoliosis.

Prognosis

In general, the severity of the scoliosis depends on the degree of the curvature and whether it threatens vital organs, specifically the lungs and heart.

Mild Scoliosis (less than 20 degrees). Mild scoliosis is not serious and requires no treatment other than monitoring.
Moderate Scoliosis (between 25 and 70 degrees). It is still not clear whether untreated moderate scoliosis causes significant health problems later on. Some studies have found no difference in either back pain or survival rates in adult untreated patients versus the general population. In one study, adults with moderate scoliosis had normal lung function, although they had difficulty exercising. (This low exercise tolerance might have been because many patients with scoliosis do not engage in regular physical activity.)
Severe Scoliosis (over 70 degrees). If the curvature exceeds 70 degrees, the severe twisting of the spine that occurs in structural scoliosis can cause the ribs to press against the lungs, restrict breathing, and reduce oxygen levels. The distortions may also affect the heart and possibly cause dangerous changes.
Very Severe Scoliosis (Over 100 degrees). Eventually, if the curve reaches over 100 degrees, both the lungs and heart can be injured. Patients with this degree of severity are susceptible to lung infections and pneumonia. Curves greater than 100 degrees increase mortality rates, but this problem is very uncommon in America.

Some experts argue that simply measuring the degree of the curve may not identify patients in the moderate and severe groups who are at greatest risk for lung problems. Other factors (spinal flexibility, the extent of asymmetry between the ribs and the vertebrae) may be more important in predicting severity in this group.

Scoliosis is associated with osteopenia, a condition characterized by loss of bone mass. About 27 - 38% of adolescent girls who have scoliosis also have osteopenia. Some experts recommend measuring bone mineral density when a patient is diagnosed with scoliosis. The amount of bone loss may help predict how severely the spine will curve. Preventing and treating osteopenia may help limit further curve progression.

If not treated, osteopenia can later develop into osteoporosis. Osteoporosis is a more serious loss of bone density that is common among postmenopausal women. Adolescents who have scoliosis are at increased risk of developing osteoporosis later in life. [See In-Depth Report#18: Osteoporosis.]

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

After 20 years or more, scoliosis patients who were previously treated with surgery experience small but significant physical impairment, (mainly mild back problems), compared to their peers without scoliosis. In one study, 65% of patients reported some low back pain compared to 47% of people without a history of scoliosis. In general it was mild, although 45% of patients reported having to take days off from work compared to 19% of nonscolosis patients. In another study, only 1.5% of the scoliosis group had severe debilitating back pain. In general, the quality of life was similar, however. Pain also did not play a major role in social limitations.

The following are some possible causes of later back problems in people with a history of treated scoliosis:

Spinal fusion disease. Patients who are surgically treated with fusion techniques lose flexibility and may experience weakness in back muscles due to injuries during surgery.
Disk degeneration and low back pain. With disk degeneration, the disks between the vertebrae may become weakened and rupture. In some patients, years after the original surgeries, particularly with the first generation of the Harrington rods, the weight of the instrumentation can cause disk and joint degeneration severe enough to require surgery. Treatment may involve removal of the old instrumentation and extension of the fusion into the lower back. Still, most patients do not experience significant back pain from these problems.
Height loss.
Scarred regions. Pain can occur from old scars in the incision areas.
Lumbar flatback. This condition is most often the result of a scoliosis surgical procedure called the Harrington technique, which eliminated lordosis (the inward curve in the lower back). Adult patients with flatback syndrome tend to stoop forward. They may experience fatigue and back and even neck pain.
Rotational trunk shift (uneven shoulders and hips).

Evidence suggests that previous treatment with braces may also cause mild back pain and more days off, but problems appear to be less than with surgery. In one study, dysfunction was comparable to people without a history of scoliosis.

Pain in adult-onset or untreated childhood scoliosis often develops because of posture problems that cause uneven stresses on the back, hips, shoulders, necks, and legs. In one study conducted 20 years after growth had stopped, two-thirds of adults who had lived with curvatures of 20 - 55 degrees reported they experienced back pain. Other studies have reported that adults with a history of scoliosis tend to have chronic and more back pain than the general population.

Nearly all individuals with untreated scoliosis at some point develop spondylosis, an arthritic condition in the spine. The joints become inflamed, the cartilage that cushions the disks may thin, and bone spurs may develop. If the disk degenerates or the curvature progresses to the point that the spinal vertebrae begin pressing on the nerves, pain can be very severe and may require surgery. Even surgically treated patients are at risk for spondylosis if inflammation occurs in vertebrae around the fusion site.

Emotional Impact in Childhood. The emotional impact of scoliosis, particularly on young girls or boys during their most vulnerable years, should not be underestimated. Adults who have had scoliosis and its treatments often recall significant social isolation and physical pain. Follow-up studies of children who had scoliosis without having strong family and professional support often report significant behavioral problems. Fortunately, current treatments are solving many of the problems that previous generations had to deal with, including unsightly bracing and extremely painful surgeries with little pain control.

Emotional Effects in Adults. Of some concern are growing numbers of adults with scoliosis. This group experiences considerable problems in general health, social functioning, emotional and mental health, as well as pain.

Older people with a history of treated scoliosis may carry negative emotional events into adulthood that have their roots in their early experiences with scoliosis. Many studies have reported that patients who were treated for scoliosis have limited social activities and a poorer body image in adulthood. Some patients with a history of scoliosis have reported a slight negative effect on their sexual life. Pain appears to be only a minor reason for such limitation.

Women who have been successfully treated for scoliosis have only minor or no additional risks at all for complications during pregnancy and delivery. A history of scoliosis also does not endanger the child. Pregnancy itself, even multiple pregnancies, does not increase the risk for curve progression. Women who have severe scoliosis that restricts the lungs, however, should be monitored closely.

Some evidence suggests a slightly higher risk for breast cancer and leukemia in patients who had multiple x-rays. Risks are highest in patients who had the largest radiation exposure, such as those who had been surgically treated.

Patients who simply received x-ray series for untreated idiopathic scoliosis or scoliosis caused by uneven length legs or hip abnormalities have a very low risk for future complications.

Click the icon to see an image of an x-ray.

Symptoms

Scoliosis is usually painless. The curvature itself may often be too subtle to be noticed, even by observant parents. Some parents may notice abnormal posture in their growing child that includes:

A tilted head that does not line up over the hips
A protruding shoulder blade
One hip or shoulder that is higher than the other, causing an uneven hem or shirt line
An uneven neckline
Leaning more to one side than the other
In developing girls, breasts appearing to be of unequal size
One side of the upper back being higher than the other when the child bends over, knees together, with the arms dangling down

Scoliosis may be suspected when one shoulder appears to be higher than the other, there is a curvature in the spine, or the pelvis appears to be tilted. The treatment of scoliosis can involve the use of a brace or surgery. Treatment is determined by the cause of the scoliosis, the size and location of the curve, and the stage of bone growth of the patient.

With more advanced scoliosis, fatigue may occur after prolonged sitting or standing. Scoliosis caused by muscle spasms or growths on the spine can sometimes cause pain. Nearly always, however, mild scoliosis produces no symptoms, and the condition is usually detected by the pediatrician or during a school screening test.

Diagnosis

The severity of scoliosis and need for treatment is usually determined by two factors:

The extent of the spinal curvature. (Scoliosis is diagnosed when the curve measures 11 degrees or more.)
The angle of the trunk rotation (ATR).

Both are measured in degrees. These two factors are usually related. For example, a person with a spinal curve of 20 degrees will usually have a trunk rotation (ATR) of 5 degrees. These two measurements, in fact, used to be the cutoff for recommending treatment. However, the great majority of 20-degree curves do not get worse. Patients do not usually need medical attention until the curve reaches 30 degrees, and the ATR is 7 degrees.

Adam's Forward Bend Test. The screening test used most often in schools and in the offices of pediatricians and primary care doctors is called the Adam's forward bend test.

The child bends forward dangling the arms, with the feet together and knees straight. The curve of structural scoliosis is more apparent when bending over. In a child with scoliosis, the examiner may observe an imbalanced rib cage, with one side being higher than the other, or other deformities.

The forward bend test is used most often in schools and doctor's offices to screen for scoliosis. During the test, the child bends forward with the feet together and knees straight while dangling the arms. Any imbalances in the rib cage or other deformities along the back could be a sign of scoliosis.

The forward bend test, however, is not sensitive to abnormalities in the lower back, a very common site for scoliosis. Because the test misses about 15% of scoliosis cases, many experts do not recommend it as the sole method for screening for scoliosis.

Other Physical Tests.

The patient walks on the toes, then the heels, and then jumps up and down on one foot. Such activities indicate leg strength and balance.
The doctor will check leg length and look for tight tendons in the back of the leg, which may cause an uneven leg length or other back problems.
The doctor will also check for neurologic impairment by testing reflexes, nerve sensation, and muscle function.

Proper diagnosis is important. A misjudgment can lead to unnecessary x-rays and stressful treatments in children not actually at risk for progression. Unfortunately, although measurements of curves and rotation are useful, no test exists yet to determine whether a curve will progress.

Inclinometer (Scoliometer). An inclinometer, also known as a Scoliometer, measures distortions of the torso. The procedure is as follows:

The patient bends over, arms dangling and palms pressed together, until a curve can be observed in the upper back (thoracic area).
The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve.
The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also measured.
Measurements are repeated twice, with the patient returning to a standing position between repetitions.
If results show a deformity, x-rays probably need to be performed to determine the extent.

Some experts believe the Scoliometer would make a useful device for widespread screening. Scoliometers, however, indicate rib cage distortions in more than half of children who turn out to have very minor or no sideways curves. They are therefore not accurate enough to guide treatment.

Currently, x-rays are the most cost-effective method for diagnosing scoliosis. Experts hope that accurate, noninvasive diagnostic techniques will eventually be developed to replace some of the x-rays used to monitor the progression of scoliosis. To date, imaging techniques under investigation appear to be fairly accurate for detecting scoliosis in the upper back (the thoracic region), but not scoliosis in the lower back (the lumbar region).

X-Rays. If screening indicates scoliosis, the child may be sent to a specialist who takes an initial x-ray and monitors the child every few months using repeated x-rays. X-rays are essential for an accurate diagnosis of scoliosis in that they:

Reveal the degree and severity of scoliosis.
Identify any other spinal abnormalities, including kyphosis (hunchback) and hyperlordosis (swayback).
Help the doctor determine whether skeletal growth has reached maturity.
X-rays taken when patients are bending forward can also help differentiate between structural and nonstructural scoliosis. Structural curves persist when a person bends over, and nonstructural curves tend to disappear. (Muscle spasms or spinal growths may sometimes cause nonstructural scoliosis that shows a curve on bending.)
Children and young adolescents who have mild curves and in older adolescents who have more severe curvatures but whose growth has stopped or slowed need x-rays every few months to detect increasing severity. Young people who are diagnosed with scoliosis should keep their x-rays indefinitely in case they develop back problems later in adulthood and need to be re-examined.

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) is an advanced imaging procedure that does not use radiation, as x-rays do. It is expensive, however, and not generally used for an initial diagnosis. MRI can, nevertheless, identify spinal cord and brain stem abnormalities, which some studies indicate may be more prevalent than previously believed in children with idiopathic scoliosis. It also may be particularly useful before surgery for detecting defects that could lead to potential complications.

Click the icon to see an image of a MRI scan.

Because frequent x-rays may be required for young children with scoliosis, parents should be sure that x-ray technicians take all necessary protective measures. Experts are concerned about the long-term effects of radiation on sensitive young organs, particularly about a possible increase in the risk for cancer. Studies have reported an increased risk for cancer in women and men who, because of scoliosis, had been exposed to diagnostic x-rays in their childhood and adolescence.

X-ray techniques have become safer in recent years, and technicians can reduce the hazards with the following simple measures:

Directing x-ray beams through the patient from back to front, rather than the reverse.
Using x-ray filters that absorb some of the beam.
Using fast film to reduce exposure by two to six times.
Placing lead aprons or shields over parts of the body that are not being x-rayed.

There are various methods for determining and classifying the extent of the curve.

Cobb Method. The technique known as the Cobb method nearly always calculates the degree of the curve.

On an x-ray of the spine, the examiner draws two lines: One line extends out and up from the edge of the top vertebrae of the curve. The second line extends out and down from the bottom vertebrae.
The technician then draws a perpendicular line between the two lines.
Measuring the intersecting angle determines the degree of curvature.

The Cobb method is limited because it cannot fully determine the flexibility or the three-dimensional aspect of the spine. It is not as effective, then, in defining spinal rotation or kyphosis. It also tends to over-estimate the curve. Other diagnostic tools are needed then to make a more accurate diagnosis.

Classifying the Curve.Classification of the curve allows the doctor to identify patterns that can help determine treatments, particularly specific surgical techniques. The following are examples:

King Classification. The King classification classifies scoliotic curves as one of five patterns, which can help determine surgical treatments. It has limitations, however, and is not very useful for advanced surgical techniques.
Lenke Classification. Lenke classification takes more features of the curve into consideration and is proving to be more reliable. This includes six curve patterns plus additional factors that modify each of these curves.

Three-Dimensional Modeling Techniques. Advanced computer modeling techniques are able to create three dimensional images using x-rays or other two-dimensional images. They allow doctors to observe the spinal distortions and eventually could reduce the number of x-rays currently needed to monitor scoliosis and help surgeons determine optimal surgical procedures.

Even if the curve is accurately calculated, it still remains difficult to predict whether the scoliosis will progress. A recent report indicates that measuring the nerve conduction activity of the muscles supporting the spine may help predict subsequent progression in children with scoliosis. In addition, computer models are being used to better predict risk. One approach requires measuring 21 radiographic and clinical indicators and entering them into a computer program. The technique takes less than 20 minutes per patient, and studies found it to be up to 80% accurate in determining progression of curvature.

One way of predicting whether or not the curvature will progress is knowing when the child will stop growing:

If the child has years to grow, then the spine has more time to progress.
If the child will stop growing within a year, then progression should be very slight. (However, some progression continues in nearly 70% of curves even after the spine has matured.)

Knowing the child's age is, of course, the first step in estimating the end of growth. In addition, other methods can help predict the end of the growth stage. One method is called the Risser sign, which grades the amount of bone in the area at the top of the hipbone. A low grade indicates that the skeleton still has considerable growth; a high grade means that the child has nearly stopped growing and the curve is unlikely to progress much further. The Risser scale differs between genders, and, in boys, a high grade does not always signify the end of progression.

Screening programs for scoliosis, which began in the 1940s, are now mandatory in middle or high schools in many states, but there is considerable debate over whether screening should be routine.

Arguments Against Routine Screening. The U.S. Preventive Services Task Force does not recommend routine screening to detect adolescent scoliosis for the following reasons:

Screening tests are not accurate and depend too much on the skill of the examiner.
Schools often refer children with minor curves who are not at any risk for a progressive or serious condition to doctors, and such over-referrals add considerably to the costs of the health system. In one major study, 94% of the children referred to a doctor by the school did not require treatment. (Over 2,000 children were screened in order to find only 5 children who did need treatment.)
A long-term study of untreated patients with late-onset scoliosis indicates that these patients are productive and functional at a high level at 50-year follow-up. Patients with scoliosis have no greater danger for significant lung problems than the general population until their curves reach 60 - 100 degrees, making early screening unnecessary.

Experts against screening argue that such programs result in early treatments that either will not prevent curve progression and surgery or are unnecessary in the first place since curvatures often do not progress at all.

Arguments for Routine Screening. The American Academy of Orthopaedic Surgeons recommends that girls be screened twice, at ages 10 and 12, and that boys be screened once, at 13 or 14. The American Academy of Pediatrics recommends, however, scoliosis screening at ages 10, 12, 14, and 16 years. (In one study, over 40% of high school sophomores with newly diagnosed scoliosis had shown no signs of the disorder in earlier screening tests.) Other experts make the following arguments for universal screening:

Universal screening is useful for producing information on scoliosis that may eventually lead to knowledge of its cause and ways to prevent it.
Braces have proven to be effective, and early treatment can be important.
Without screening, the chances are slim that children with scoliosis will be diagnosed at an early stage if parents rely only on examinations by a family doctor or pediatrician. Such doctors often do not even look at backs and, if they do, they tend to use only the forward bend test, which is not accurate.

Some experts argue that widespread screening would be cost effective if schools had reasonable guidelines for determining which children should see a doctor for further testing. The following are some suggested guidelines for determining the need for a doctor referral:

Children should be sent to a doctor only if they have a 30-degree curve. (A 20-degree curve with a 5-degree trunk rotation has been the criteria for recommending treatment, although up to 80% of 20-degree curves do not get worse.)
Children with curves between 20 and 30 degrees should be screened every 6 months.

Such guidelines would detect about 95% of all genuinely serious cases while referring only 3% of all children tested for follow-up, thereby cutting costs without jeopardizing children.

Treatment

The treatments for scoliosis are not always straightforward. Some young people do not need treatment at all -- only careful observation. When treatment is warranted, several options, including braces and different surgical procedures, can help.

The general rule of thumb for treating scoliosis is to monitor the condition if the curve is less than 20 degrees. Curves greater than 25 degrees, or those that progress by 10 degrees while being monitored, may require treatment. Whether scoliosis is treated immediately or simply monitored is not an easy decision, however. The percentage of cases that will progress more than 5 degrees can be as low as 5% in certain cases or as high as 50 - 90%, depending on the severity of the curve or other predisposing factors:

Age. In general, the older the child the less likely the curve will progress. Scoliosis in a child under 10, for example, is more likely to progress than scoliosis in an adolescent. Experts estimate that curves less than 19 degrees will progress 10% in girls ages 13 - 15 years and 4% in children older than 15. (In some rare, severe cases, a curve may worsen even after a child has received treatment and stopped growing because of the weight of the body pressing against the abnormal curve.)

Gender. Girls have a higher risk for progression than boys.

Location of the Curvature. Thoracic curves, those in the upper spine, are more likely to progress than thoracolumbar curves or lumbar curves, those of the middle to lower spine.

Severity of the Curvature. The higher the degree of curvature the more likely the chance of progression and the more likely the lungs will be affected. Some experts argue that the degree of the curve alone may not identify patients with moderate and severe scoliosis who are at greatest risk for complications and therefore need treatment. For example, spinal flexibility and the extent of asymmetry between the ribs and the vertebrae may be more important than the curve degree in predicting severity in this group.

Presence of Other Health Conditions. Children in poor health may suffer more from stressful scoliosis treatments than other children. On the other hand, children who have existing conditions and are predispose to lung and heart problems may warrant immediate, aggressive treatment.

For example, a young man of 18 who has a curvature of 30 degrees may require no treatment because his growth has probably almost stopped, and his gender puts him at lower risk. A young girl of 10, however, with the same curvature requires immediate treatment.

In general, the following criteria are used to determine whether a patient should receive braces and conservative therapies or surgery:

Braces tend to be used in children with curvatures between 25 - 40 degrees who still will be growing significantly.
Surgery is suggested for patients with curvatures over 50 degrees, in untreated patients, or when braces have failed. In adults, scoliosis rarely progresses beyond 40 degrees, but surgery may be required if the patient is in a great deal of pain or if the scoliosis causes neurologic problems.

The choice may not be so straightforward in certain cases, and patients should discuss all options with their doctor.

In Children and Adolescents. After a mild curve is detected, a more difficult step is required: predicting whether the curve will progress into a more serious condition. Although as many as 3 in every 100 teenagers have a condition serious enough to need at least observation, progression is highly variable and individual.

In a study of patients whose curves did progress after diagnosis, 34% progressed more than 10 degrees, 18% progressed more than 20 degrees, and 8% progressed more than 30 degrees. Doctors cannot rely on any definitive risk factors for curve progression to predict with any certainty which patients will need aggressive treatment. Some evidence suggests the following factors may help determine patients at lower or higher risk:

Being female, particularly if taller than average.
Being younger at the onset of scoliosis.
Having a greater angle of curvature. For example, at 20 degrees, only about 20% of curves progress. Young people diagnosed with a 30-degree curve, however, have a risk for progression of 60%. With a curve of 50 degrees, the risk is 90%.
Curvatures caused by congenital scoliosis (spinal problems present at birth). These may progress rapidly.
Treatment with growth hormone. (Studies are mixed on whether this treatment poses any significant risk, although strict monitoring is still essential in young patients being given growth hormone.)

Curvatures may be less likely to progress in girls whose scoliosis was low in the back and whose spine was out of balance by more than an inch. Height also comes into play. For example, a shorter-than-average girl of 14 with low-back scoliosis of 25 - 35 degrees but whose spine is imbalanced by over an inch would have almost no risk. The same degree of curvature in the chest region of a tall 10-year old girl whose spine was in balance, however, would almost certainly progress.

In Adults. In rare cases, unrecognized or untreated scoliosis in youth may progress into adulthood, with the following curvatures posing low to high risk:

Curvatures under 30 degrees almost never progress
Predicting progression at curves around 40 degrees is not clear
Curvatures over 50 degrees are at great risk for progression

Managing Scoliosis

Exercise has many health benefits and is important for maintaining strength and muscle tone and stabilizing weight. Stretching exercises may be beneficial in children whose scoliosis is due to uneven leg lengths or a shortened tendon.

Strengthening the Muscles That Turn the Torso. A promising approach focuses on training and strengthening the muscles that turn the torso. Studies using specific equipment (MedX Torso Rotation machine) are showing promise. In a 2003 study, 16 of the 20 patients experienced curve reduction, and no curves progressed. In an earlier study, patients increased strength from 12 - 40%. One girl with a severe lumbar curve required surgery, but the remaining 11 patients had no progression of curvature, and 4 of the patients experienced a reduction in their curvature. Treatment did not involve braces. Clinical trials using this approach are underway. Exercising the torso to build muscle strength is important, in any case, in conjunction with braces.

ASCO Scoliosis Treatment Method. ASCO Scoliosis Treatment Method is a Russian approach that consists of isometric and stretching exercises, vibration, spinal manipulation, and electrical muscle stimulation. Some U.S. centers are reporting success in halting curve progression, but more research is needed to determine possible benefits.

Biofeedback. Researchers have investigated biofeedback on the premise that people receiving a signal to improve posture when slumping may, in some cases, reduce their spinal deformities. (Some experts believe that braces work only because the young patients self-correct their curves by retraining their posture to avoid the discomfort of the brace.)

Chiropractic Care. Several case reports suggest that chiropractic manipulation of the spine may help stop progression of mild curves. However, no rigorous studies have proved this. One small study reported no benefits from chiropractic in girls with spinal curves less than 20 degrees. (About 80% of such curves will not progress significantly without any treatment.)

Airway Ventilation at Night. Some research has focused on the use of airway systems, such as nasal continuous positive airflow pressure, for patients with severe scoliosis and reduced lung capacity. Patients use such systems during the night to force air into the upper airways and into the lungs. In one study, the use of these devices reduced hospitalization and improved lung function, shortness of breath, and fatigue. Such systems also can treat sleep apnea, a common sleep disorder.

Breathing Exercises. Breathing exercises may help improve lung function in children with scoliosis, and signs of lung problems.

When a difference in leg lengths causes secondary scoliosis, adding lifts to the heels may decrease a mild curvature. In one study, this practice reduced the curvature by an average of 5.3 to 7.5 degrees. (Curvatures were all less than 20 degrees.) Patients with the greatest curvature experienced some muscle pain, fatigue, and even nausea during the first few days they were using the lifts, but these symptoms eased within 10 days.

Braces

A brace can prevent further progression of moderate curves of (24 - 40 degrees). However, a brace will almost never reverse an existing curve and is only used to stop progression. One study reported overall success rates of around 74%, but results vary widely depending on the length of time the brace is worn, the type of brace, and the severity of the curve. The great majority of subjects in scoliosis studies are girls. Limited data suggest that in boys compliance rates are low, and braces are not effective.

Compliance with wearing a brace correlates strongly with success rate. In analysis of 34 patients, the compliance rate for the patients whose curve progressed by more than 5 degrees was 62%, while the compliance rate for the patients who did not progress was 85%.

In overweight patients with adolescent idiopathic scoliosis, braces appear to be less effective than in those who are not overweight. In one 10-year multicenter retrospective study, overweight patients were about three times more likely to have an unsuccessful result with braces than were people of normal weight.

A brace is one type of treatment for scoliosis. The brace works by exerting pressure on the back and ribs to push the spine in a straighter position. The brace usually fits snugly around the torso and can come in many styles. In a child who is still growing, bracing is usually recommended to help slow the progression of the curve. The brace is usually worn full-time until the growth of the bones has stopped.

Many experts have questioned whether a brace is any better than nature in halting curvature progress. Early studies found that braces were successful in halting progression in only half of cases (the same rate as no treatment at all). In recent years, however, braces have improved. Many now fit under the arms and can be worn under clothing, so that patients are much more likely to use them for longer periods during the day, which greatly affects their success rates.

Wearing the brace for the prescribed time is difficult but essential for any success. A team approach, with several health professionals involved, is beneficial and often necessary to support the patient through the bracing process. An orthopedic surgeon interprets the x-rays, assesses the potential progression of the scoliosis, and plans the treatment with the patient and family. If a brace is used, an orthotist measures and fits the patient with the device. A physical therapist tailors an exercise program best suited for the patient. A nurse may also coordinate the treatment plans and provide physical and emotional support.

Milwaukee Brace. A full torso brace called the Milwaukee brace was the standard treatment until a decade ago. It is still used particularly for high curves.

The device contains a wide flat bar in front and two smaller ones in back. These bars attach to a ring around the neck that has rests for the chin and back of the head. One study determined that correcting the curve occurs best if the patient lies on their chest when wearing the brace. Some researchers suggest that increasing the tension on the chest straps might add benefit. The brace is also periodically adjusted for growth.

The brace needs to be worn 23 hours a day, with relief during bathing and exercise only. Compliance is a major problem. In one study, only 15% of patients wore the Milwaukee brace as directed. It is a particularly difficult brace to endure wearing; one woman who had worn it for 7 years during adolescence remembered being invisible during her school years, ignored and shunned by other children.

The Boston and TLSO Braces. Molded braces called thoracolumbar-sacral orthoses (TLSOs), most often the Boston brace, come up to beneath the underarms and can be fitted close to the skin so they do not show beneath clothing. It appears to be effective for mid-back and lower curves. In one study, treatment was judged successful in 61% of adolescents who wore Boston braces, and success correlated with wearing the brace more than 18 hours a day. Wearing the brace for 16 hours a day may still be beneficial, although the risk for curve progression is significantly higher the less time the brace is worn. These braces have problems; they are hot, reduce lung capacity by nearly 20%, and cause mild, temporary changes in kidney function.

The Charleston Bending Brace. The Charleston Bending Brace is worn only at night. Some doctors question its value, although it appears to be suitable for small, flexible curves. In a 2002 study, it was equally effective as the Boston brace. Other studies have reported success rates of 56 - 66% in patients who wore the brace as directed. Still, more than 10% of the patients using either brace eventually needed surgery.

Additional Braces in Development. New braces are being developed in an attempt to improve compliance and results. Some examples are:

The Providence brace is a computer-fitted device that is worn only at night. It is specifically designed for the individual curvature abnormalities, and early studies are showing promise.
A bracing method called the SpineCor uses adjustable bands and a cotton vest that allows flexibility. A 2003 study reported that after 2 years, the brace corrected the curve by 5 degrees in more than half the patients, while 38% were stabilized and only 7% had curvature that worsened by more than 5 degrees. A recent trial of 24 girls with idiopathic scoliosis compared the SpineCor with a TLSO-type brace. The study indicated that the SpineCor did not halt curvature progression associated with idiopathic scoliosis during the pubertal growth spurt whereas the TLSO device did.
The custom-fitted TriaC brace exerts pressure in specific areas of the back to allow greater comfort and flexibility. It may be less conspicuous than some of the older braces.

Studies are needed to determine if these or other new braces provide any additional value.

According to a 2003 study, compliance in wearing the brace averages 65% (although it varied from 8 - 90%). Patients were apt to wear them at night but often wore them sporadically during the day. The quality of life can vary by the type of brace worn. In one study, patients who had the Milwaukee brace reported greater impairment than patients with the Boston, TSLO, or Charleston braces. The choice of brace should be one that will be the most effective for a particular patient with the lowest impact on quality of life. Young people often refuse to wear braces, even the newer models, and emotional support from the family and professionals is extremely important to help a child accept the process and sustain compliance. On a positive note, one study reported that brace treatment did not negatively affect the self images of the adolescents who had to wear them.

For children who require braces, an exercise program helps boost well being, improves compliance with treatment, and keeps muscles in tone so that the transition period after brace removal is easier.

An exercise and physical therapy program is important to maintain or achieve the following:

Chest mobility.
Proper breathing. In one study, young girls who wore the Boston brace and performed aerobic exercises for 30 minutes four times a week experienced improved lung function, whereas lung function declined in girls who did not exercise.
Muscle strength (especially in the abdominal muscles).
Flexibility in the spine. One small study showed that patients who performed exercises improving flexibility in the torso experienced less spinal twisting and had improved curvature.
Correct posture. Practicing correct posture, especially in front of a mirror, is an extremely important part of any physical therapy program. A patient who is accustomed to a curved spine may have the sensation of being crooked when first taught to properly align the spine. Practicing in front of a mirror provides a reality check.
Patients must also learn to conduct daily activities while wearing the brace. Patients tend to comply with physical therapy in the period when the brace is first being used. They typically stop exercising when they have gotten used to the brace, however, and resume exercising only near the time the brace is being removed. Patients who don't stay with the program throughout the duration of brace use experience a weakening in the back at the time of removal.

Surgery

The goals of scoliosis surgery are threefold:

Straighten the spine as much as possible in a safe manner
Balance the torso and pelvic areas
Maintain correction

It takes a two-part process to accomplish these goals:

Fusing (joining together) the vertebrae along the curve
Supporting these fused bones with instrumentation (steel rods, hooks, and other devices) attached to the spine

There are many surgical variations that use different instruments, procedures, and surgical approaches to treat scoliosis. All of the operations require meticulous skill. In most cases, success depends less on the type of operation than on the skill and experience of the surgeon. The cause of scoliosis often determines the type of procedure. Parents of patients or adult patients should not be shy in asking the surgeon and hospital about their experience with the specific procedures being considered.

Surgery is usually recommended for the following children and adolescents with idiopathic scoliosis:

All young people whose curve exceeds 50 degrees.
Growing children whose curve has gone beyond 40 degrees. (There is still some debate, however, about whether all children with curves of 40 degrees should have surgery.)
Older children who have surgery tend to experience improved well-being from the changes in their appearance, even if they have no actual improved physical functioning.

Surgery may be required for the following children at as early an age as possible.

Those whose scoliosis is due to inborn abnormalities. (The younger they are when surgery is performed the better their chances for success.)
Children with multiple physical handicaps.

Procedures will differ depending on whether a child has idiopathic scoliosis, or scoliosis due to muscle and nerve disorders (such as muscular dystrophy or cerebral palsy). In the latter cases, children also need a team approach to reduce their risks for serious complications.

Before the operation, a doctor conducts a complete physical examination to determine leg lengths, muscle strength, lung function, and any postural abnormalities. The patient receives training in deep breathing and effective coughing to avoid lung congestion after the operation. The patient should also receive training in turning over in bed in a single movement (called log-rolling) before the operation. Psychologic intervention using cognitive-behavioral methods that help young patients cope may be very helpful in reducing anxiety and pain after surgery.

Patients are encouraged to donate their own blood before the operation for use in possible transfusions. The patient should have no sunburn, rashes, or sores on the back before the operation, which could increase the risk for infection.

Most scoliosis operations involve fusing the vertebrae. The instruments and devices used to support the fusion vary, however.

In the fusion procedure, the surgeon will:

Slice flaps to expose the backs of the vertebrae that lie along the curve.
Remove the bony outgrowths along the vertebrae that allow the spine to twist and bend.
Lay matchstick-sized bone grafts vertically across the exposed surface of each vertebra, being careful that they touch adjoining vertebrae.
Fold the flaps back to their original position, covering the bone grafts.
These grafts will regenerate, grow into the bone, and fuse the vertebrae together.

Depending upon the severity and responsiveness to other treatment, a doctor may recommend surgery for scoliosis. Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The surgeon lays bone grafts across the exposed surface of each vertebra. These grafts will regenerate, grow into the bone, and fuse the vertebrae together. The bones are held in place with one or two metal rods held down with hooks and screws, helping to support the fusion of the vertebrae.

Graft Materials. A surgeon takes bone grafts from the patient's hip, ribs, spine, or other bones (called autografts). This is the best quality bone. However, because autografts are taken directly from the scoliosis patient, the operation is longer and the patient experiences more pain afterward. Researchers are investigating allografts, bone grafts taken from another person or a cadaver. This would reduce the pain and duration of the operation. Allografts, however, pose an increased risk for infection from the donor.

Some surgical centers now perform spinal fusions in adults using a biologically-manufactured human bone protein instead of bone grafts. RhBMP-2 (INFUSE Bone Graft) contains a bone morphogenetic protein (BMP) that helps the body grow its own bone. A surgeon inserts the protein into a pair of thimble-like cages, which are implanted between the spinal vertebrae. The cages help stabilize the spine, while the protein prompts new bone growth. Doctors hope that this new procedure can eliminate the pain of autografts and the risk of infection of allografts. Results from preliminary studies have been promising. BMP treatments are currently approved only for adults.

Healing. The healed fusions harden in a straightened position to prevent further curvature, leaving the rest of the spine flexible. It takes about 3 months for the vertebrae to fuse substantially, although 1 - 2 years are required before fusion is complete. Fusion stops growth in the spine, but most growth occurs in the long bones of the body (such as in the legs), anyway. Patients will most likely gain height from both growth in the legs and from the straighter spine. Patients may walk at a slightly slower pace after fusion, but balance may improve, and sports activities are not restricted after the procedure.

Harrington Procedure. Until 10 years ago, the standard instruments used in fusion procedures were those of the Harrington procedure, first developed in the 1960s:

To support the fusion of the vertebrae, the surgeon uses a steel rod, extending from the bottom to the top of the curve. (More than one rod may be used depending on the type of curve and whether outward curvature of the spine is present.)
The rod is attached by hooks that are suspended from pegs inserted into the bone.
Similar to changing a tire, the steel rod is jacked up and then locked into place to support the spine securely. The surgeon is then ready to fuse the vertebrae together.
After this operation, patients must wear a full body cast and lie in bed for 3 - 6 months until fusion is complete enough to stabilize the spine.
After 1 - 2 years, the steel rod is not really necessary, but it is almost always left in place unless infection or other complications occur.

The Harrington procedure is very difficult to undergo, particularly for young people, and although the operation can achieve a correction of the curve of over 50%, studies have reported a loss in this correction of between 10 - 25% over time. The procedure does not correct the rotation of the spine and, therefore, does not improve an existing rib hump that was caused by the rotation. The operation does not interfere with normal pregnancies and deliveries later in life.

Certain complications may occur from this procedure:

About 40% of Harrington patients have a condition called the flat back syndrome, because the procedure eliminates normal lordosis (the inward curving of the lower back). Flat back syndrome from the Harrington procedure does not cause any immediate pain. In later years, however, the disks may collapse below the fusion, making it difficult to stand erect, and the condition can cause significant pain and emotional distress.
Studies have reported that 5 - 7 years after their surgery, between a fifth and a third of patients who had the Harrington procedure experienced low back pain. (In one study, only 3% had experienced back pain before surgery.) In such cases, however, the pain was not severe enough to interfere with normal activities and did not require additional surgery.
Children younger than age 11 whose skeleton is immature and who have the Harrington procedure have a fairly high risk for a specific curve progression called the crankshaft phenomenon. This condition occurs when the front of the fused spine continues to grow after the procedure. The spine cannot grow longer, so it twists and develops a curvature. In one study that followed patients for 5 - 16 years, crankshaft curve progression was moderate, however, with the Cobb angle averaging 9 degrees and rotation averaging 7 degrees.

Cotrel-Dubousset Procedure. The Cotrel-Dubousset procedure not only corrects the curve but also may help correct rotation, and it does not cause flat back syndrome.

With this procedure, a surgeon cross links parallel rods for better stability in holding the fused vertebrae. Improvement in correction averaged 66% in one study, with a later correction loss reported to be 5%. (Other studies have reported loss of curvature correction at less than 2%.) Over 95% of patients reported the results to be good or very good (only 86% of patients who had the Harrington procedure experienced the same levels of satisfaction). Patients often go home in 5 days and may be back in school in 3 weeks.

Complication rates are similar to the Harrington procedure but with some differences:

Operation time and blood loss are greater than with the Harrington procedure.
Cotrel-Dubousset and other procedures that are designed to reverse the rotation of the spine have less risk for flat back syndrome, but they have a higher risk for spinal imbalance than the Harrington procedure.
Failure rates are about 25% after 10 years, which is very high. Experts hope that the advances in current scoliosis procedures will help reduce the long-term adverse effects.

The Texas Scottish-Rite Hospital (TSRH) Instrumentation. The Texas Scottish-Rite Hospital (TSRH) instrumentation is similar to the Cotrel-Dubousset procedure in that it uses parallel rods and other devices that reverse rotation as well as improve curvature. TSRH, however, uses smooth rods and hooks that are designed to make removal or adjustment easier later on if complications arise. Complications are similar to the Cotrel-Dubousset procedure.

Additional Forms of Instrumentation. Other instrumentation procedures have refined the hardware used in the Harrington and Cotrel-Dubousset operations.

After surgeons developed Luque instrumentation to help maintain normal lordosis, experts hoped that bracing would not be needed afterward. Several studies showed, however, that without braces, correction was lost after this operation, and the procedure may have a higher risk for spinal cord injury than other standard procedures. Luque instrumentation is used primarily in people whose scoliosis is due to problems of nerves and muscles, such as in children with cerebral palsy.
Wisconsin segmental spine instrumentation (WSSI) is as safe as the Harrington rod and nearly as strong as the Luque instrumentation.
The Dorsal Dynamic Spondylodesis (DDS) system, under testing in Germany, is a semirigid system that allows for greater flexibility of the spine.

Instrumentation for Anterior Approach. The anterior approach, in which the surgeon performs the operation by opening the chest wall, requires specific hardware. Halm-Zielke instrumentation, for example, uses TSRH instrumentation with bone grafts constructed from ribs to prop open the spaces between the disks. It allows true three-dimensional curve correction. However, it does not solve specific problems with this approach -- higher risks for kyphosis (an outward curve) and pseudoarthrosis (a false joint at the fusion site). Variants using two rod systems, fusion cages, or other instruments appear to improve this procedure.

Posterior Approach (Through the Back). Many surgeons use a posterior approach for scoliosis, which reaches the surgical area by opening the back of the patient. It has been the gold standard for decades and is generally used with Harrington instrumentation. The posterior approach has advantages and disadvantages:

Advantages. Surgeons are familiar with it, so fusion rates are excellent, curve correction is good, and it has few complications.
Disadvantages. Preadolescent children are at risk for the crankshaft phenomenon (a worsening of the curve) later on. (Newer posterior instrumentation, such as the Isola instrumentation, may prevent this occurrence.) The posterior approach also does not always correct hypokyphosis (the loss of normal outward curvature) in the thoracic (upper) spine. The procedure is not always effective for curves in the thoracolumbar region (where the upper and lower spine meet) and may cause spinal abnormalities there.

Anterior Approach (Through the Front). Increasingly, surgeons are using the anterior approach, in which the surgeon performs the operation through the chest wall (called a thoracotomy). With the anterior approach, the surgeon makes an incision in the chest, deflates the lung, and removes a rib in order to reach the spine. This rib can be used during the operation as a strut to support the spine. It also may be repositioned within the patient until it is used for bone grafting during fusion.

The anterior approach also has its advantages and disadvantages:

Advantages. Because the frontal approach allows the procedure to be performed higher up in the spine than with standard procedures, the patient may have a lower risk for lower-back injury later on. In addition, transfusion rates are much lower with the anterior approach. With increasing experience, the anterior approach is as effective as the posterior approach.
Disadvantages. It is a more recent procedure than the posterior approach, and, among inexperienced surgeons, carries a higher risk for complications than in the more standard posterior approach. One study noted poorer lung function 2 years after surgery than with the posterior approach, possibly because the wide chest incision impairs the chest muscles, which can affect lung function afterward. Anterior instrumentation poses a risk for hyperkyphosis (exaggerated outward curvature) and a higher risk for pseudoarthrosis, a painful condition in which a false joint develops at the fusion site. Hardware failure rates may also be higher in the anterior approach than in the posterior approach. Increasing experience and newer hardware designs are reducing many of these problems.

The Combined Anterior-Posterior Approach. The combination approach uses an anterior approach first, which allows better correction of the problems. The fusion part of the operation is done with the posterior approach. This is a very long and complex procedure. It appears to be safe, however, and is proving to be useful, even in very young patients, for preventing the crankshaft phenomenon. It also may correct large rigid curves and specific severe curves in the thoracic spine.

Researchers are evaluating new approaches to treating thoracic scoliosis in adolescents and children. Researchers in Germany are studying the effects of implanting a vertical expandable prosthetic titanium rib. This implant expands the thoracic cavity, thereby correcting the curvature and allowing spinal, thoracic, and lung growth. Early experience with 15 children showed improvement of thoracic insufficiency syndrome and ability to sit, in addition to greatly improvement cosmetic appearance.

Researchers in the U.S. recently compared the radiographic and clinical outcomes and pulmonary function in patients treated with either anterior thoracoscopic or traditional posterior surgery. The anterior thoracoscopic surgery uses a video-assisted anterior approach and recently developed spinal instrumentation. There were 28 patients in the thoracoscopic group (average, 14.6 years of age) and 23 patients in the posterior fusion group (average, 14.3 years of age). The researchers found no significant differences between the groups in terms of kyphosis, coronal balance, or tilt angle. Advantages of the anterior thoracoscopic approach include the need for fewer vertebral levels fused, less blood loss, and lower transfusion rate, yet the operative time was nearly 2 times longer than for the posterior approach.

While both of these new treatments have shown some early positive results, more research will be needed to determine their true value.

Complication rates are high (nearly 10%) with any of these procedures, including the standard Harrington method and the newer Cotrel-Dubousset procedure.

Complications for all procedures include allergic reactions to anesthesia and the following:

Bleeding. Standard procedures increase the risk for major blood loss during the procedure. Patients are encouraged to donate blood before the operation for use in possible transfusions. Children sometimes require more than one transfusion following surgery. Researchers are investigating various methods for reducing the need for transfusions.

In one study, patients received erythropoietin (rhEPO) before the procedure. RhEPO is a hormone that acts in the bone marrow to increase the production of red blood cells. Patients who received this hormone, particularly those with idiopathic scoliosis, needed fewer transfusions and spent less time in the hospital than those who did not receive rhEPO.

Newer endoscopic techniques are reducing the need for transfusions.

Postoperative Pain. Some pain always follows these procedures, requiring intravenous administration of potent painkillers right after the operation (endoscopic procedures may require only mild pain relievers). Of some concern is a study suggesting that the use of NSAIDs, or nonsteroidal anti-inflammatory drugs (aspirin, Motrin, Advil), for pain relief right after fusion may increase the risk for fusion failure. Until more research is conducted, these common painkillers should not be routinely used immediately after surgery.

Infection. Infection is always a risk with any operation. One study reported changes in the immune system for about 3 weeks after surgery, which indicated a greater risk for infection. Researchers recommended being very vigilant for signs of infection, including in the pancreas and urinary tract. Doctors also recommend antibiotics, given by injection for 2 - 5 days after surgery and by mouth for 1 - 2 weeks longer.

Nerve Damage. Patients often worry about neurologic injuries, but the risk is actually very low. In general, nerve injury occurs in 1% of patients, with the risk highest in adults. If neurologic damage occurs, it most often causes muscle weakness. Paralysis is very rare and can be prevented using monitoring techniques during the operation. Nearly all monitoring procedures use a so-called wake-up test, in which the patient is brought out of anesthesia during or at the end of the procedure and assessed for sensations to be sure no injury has occurred. One simple method is to wake patients up in the middle of their operations and ask them to wiggle their toes. More sophisticated methods measure the electrical activity of the spinal cord; if the monitor indicates a fall in electrical response and possible injury, the surgeon adjusts his techniques to avoid further damage to the spinal cord.

Pseudoarthrosis. If the fusion fails to heal, pseudoarthrosis, a painful condition in which a false joint develops at the site, may develop. In one study, teenagers who smoked and heavier adolescents (over 154 pounds) who had hyperkyphosis (hunchback) were at higher risk for this complication. The anterior approach may pose a higher risk for pseudoarthrosis. One study reported that pseudoarthrosis may be undiagnosed, and rates may average 20% after surgery, therefore acting as a major contributor to post-surgery pain.

Disk Degeneration and Low Back Pain. Fusion in the lumbar area produces great stress on the lower back and eventually can cause disk degeneration. Loss of trunk mobility, balance, and muscle strength from surgical treatments can also cause lower back pain and chronic problems in future years. Patients who are surgically treated with fusion techniques lose flexibility; their back muscles may be weakened if they were injured during surgery. In most cases, however, the consequences are mild to moderate.

Lung Function. Some patients may develop serious lung problems after surgery. These complications are highest in children whose scoliosis is due to neuromuscular problems, such as spina bifida, cerebral palsy, or muscular dystrophy. Lung problems can occur up to 1 week after surgery. Lung function may not become completely normal until 1 - 2 months after surgery.

Other Complications. Other problems can include, but are not limited to, the following:

Hooks dislodging or a fused vertebra fracturing
Gallstones
Pancreatitis (inflammation of the pancreas). Among adolescents, this complication tends to occur more often among those who are older or who have a lower body mass index.
Intestinal obstruction

Click the icon to see an image of gallstones.

Patients must perform breathing and coughing exercises shortly after the procedure and continue them through the recovery process to rid the lungs of congestion. The patient is usually able to sit up the day after the operation, and most patients can move on their own within a week. A brace may be necessary, depending on the procedure. With the anterior approach in the upper back, patients may have some trouble with activities involving the arms and hands -- such as tying shoes and cutting food. In one study, however, occupational therapy using stretching and strengthening exercises allowed for full resumption of daily activities, including dressing, bathing, and grooming, within 3 months.

Patients are often concerned that surgery will stiffen their backs, but most cases of scoliosis affect the upper back, which has only limited movement, so that patients do not notice much difference. It may take a year or more for muscle strength to return. In some cases, the operation cannot completely correct the curve, and one leg may be shorter than the other. Heel lifts may help in this case.

Patients may need a corrective procedure called revision or salvage surgery, usually for one of these reasons:

Failure of the previous procedure
Curvature progression around the fusion site
Disk degeneration
Poor posture alignment

Minimally invasive surgery is an alternative to spinal fusion. These types of surgeries use a few small incisions and cause less scarring than standard open approaches that require wide cuts. However, these surgeries are limited to certain patients and are not yet as frequently performed as spinal fusion surgeries.

Endoscopy. In endoscopy, the surgeon makes small incisions and inserts tubes that contain tiny instruments and cameras through the incisions in order to view and execute the procedure. In most cases, the procedure occurs in two stages:

First, the surgeon uses the anterior approach to remove disk material and loosen the spine.
They follow with a posterior for fusion and instrumentation.

Recovery after surgery is rapid. Most patients are out of bed 2 days after surgery. Endoscopy causes fewer and smaller scars, and an easier recovery, than more invasive surgical approaches.

However, the endoscopic procedure for scoliosis is complicated, and few surgeons are trained to perform it. The surgery is generally used only for single curves in the upper back or for patients with a curve in the upper back and a compensating curve in the lower back. Some surgeons are now able to operate on areas below the diaphragm, including the lumbar spine. The patients must still wear a brace for 3 months after surgery. Long-term studies are required to compare results to those of standard procedures.

Growing Rod Technique. This technique is used for very young children in whom bracing has not helped. Instead of doing spinal fusion, doctors surgically insert a rod into the patient’s back. Additional surgeries are performed every 6 months to extend the rod so that the spine can continue to grow. Some growing rod techniques use a single rod, while others use two rods. Studies suggest that dual rods are stronger than single rods, which may help provide better spinal stability and correction.

Vertebral Body Stapling. Vertebral body stapling is an experimental technique that may prevent curve progression in some young patients with curves less than 50 degrees. It involves stapling the convex (outer) curve of the anterior spine (the side of the spine facing the chest), which helps stabilize and reduce progression of the inner (concave) curve. The procedure uses a special metal device that is clamp-shaped at body temperature but can be straightened when subjected to cold temperatures and inserted into the spine. When warmed up, the staple returns to its clamp shape and supports the spine.

Treatment for Adult Scoliosis

Adults who were surgically treated for scoliosis in their youth are at risk for disk degeneration and spinal fusion failure. In most adults with previous scoliosis, moderate exercise is not harmful and is extremely important for maintaining healthy supportive muscles and preventing disk degeneration. However, people who have only one or two mobile lumbar vertebrae below the area that was fused during surgery should avoid activity or exercise that causes excessive twisting on the spine. Some experts believe this may accelerate spinal degeneration.

In most cases of adult scoliosis, nonsurgical care is preferred if possible. This can include patient education, exercises, and medical treatments. Braces are not useful.

One center reported that epidural steroid injections were a beneficial alternative to surgery in patients with degenerative lumbar scoliosis.

Candidates for Surgery. In general, pain is the most common reason for surgery in adult scoliosis. Surgery may be recommended in the following cases:

Curvatures over 50 degrees with persistent pain.
Surgery is almost always recommended for adults with curvatures over 60 degrees.
Progressive mid and low back curve or low back curve with persistent pain.
Reduced heart and lung function. Most surgeons, however, will not operate on adults with severely impaired lung function and heart failure. Once this has occurred, surgery will not help improve lung capacity and may cause the condition to worsen, at least temporarily.
Significant deformity is present. Adults should not expect to achieve a completely straight spine, however. There is a high risk for nerve damage if the spine is over-corrected, and adult spines are less flexible than children's are. Usually, however, the correction achieves an acceptable cosmetic improvement.

Surgeons prefer to operate on adults under 50 years old, although surgery may be appropriate in some older people.

Standard Scoliosis Procedures in Adult Scoliosis. The procedures involve the following depending on whether the patient had been treated previously or not:

In patients who have not had previous treatment and who have degenerative lumbar scoliosis, the procedure is often a diskectomy (removal of the diseased disks) followed by scoliosis procedures (instrumentation and fusion).
In patients with previously treated scoliosis, the only remedy is removal of the old instrumentation, extension of the fusion, and implementation of new instrumentation and bone grafts.

Surgical procedures in adult scoliosis are complex and undertaken only after careful consideration and all nonsurgical methods have been exhausted. Adults have a much higher risk than children for complications, including pneumonia, infection, poor wound healing, and persistent pain. In addition, procedures in adults often involve fusion in lumbar and sacral areas (the low back), which can cause several complications. Some experts believe that the risks of operations in this area nearly always outweigh any benefits in adults. Most studies on adults have also reported low success rates.

Others argue that without an operation, the back will become unstable and painful. In addition, most studies on adults report on procedures using the old Harrington instrumentation techniques. Advances in instrumentation are increasing success rates in adults.

In a recent study, for example, adults who underwent anterior fusion and instrumentation had excellent results. In another study of newer generation instrumentation, 87% of adult patients reported satisfaction.

Wedge Osteotomy. Researchers are investigating wedge osteotomy in patients with mature spines, as corrective surgery and as an alternative to braces. In this procedure, a surgeon cuts wedges of bone from the concave side of the curve. The surgeon then straightens the spine by inserting a temporary rod and closing the cut sections. The patient needs to wear a brace and restrict activity for about 12 weeks or until the bone has healed. The patient can resume normal activities when a surgeon removes the rod, and the spine is mobile.

Resources

www.scoliosis.org -- National Scoliosis Foundation
www.srs.org -- Scoliosis Research Society
www.scoliosis-assoc.org - - Scoliosis Association
www.aaos.org -- American Academy of Orthopaedic Surgeons
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.ispine.com -- Information on the spine

References

Akbarnia BA, Marks DS, Boachie-Adjei O, Thompson AG, Asher MA. Dual growing rod technique for the treatment of progressive early-onset scoliosis: a multicenter study. Spine. 2005;30(17 Suppl):S46-S57.

Helenius I, Jalanko H, Remes V, Sairanen H, Salminen S, Holmberg C, et al. Scoliosis after solid organ transplantation in children and adolescents. Am J Transplant. 2006;6(2):324-330.

Hell AK, Campbell RM, Hefti F. The vertical expandable prosthetic titanium rib implant for the treatment of thoracic insufficiency syndrome associated with congenital and neuromuscular scoliosis in young children. J Pediatr Orthop B. 2005;14:287-293.

Hung VW, Qin L, Cheung CS, Lam TP, Ng BK, Tse YK, et al. Osteopenia: a new prognostic factor of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2005;87(12):2709-2716.

Lee WT, Cheung CS, Tse YK, Guo X, Qin L, Lam TP, et al. Association of osteopenia with curve severity in adolescent idiopathic scoliosis: a study of 919 girls. Osteoporos Int. 2005;16(12):1924-1932.

Lonner BS, Kondrachov D, Siddiqi F, Hayes V, Charf C. Thoracoscopic spinal fusion compared with posterior spinal fusion for the treatment of thoracic adolescent idiopathic scoliosis. J Bone Joint Surg. 2006;88A:1022-1034.

Luhmann SJ, Bridwell KH, Cheng I, Imamura T, Lenke LG, Schootman M. Use of bone morphogenetic protein-2 for adult spinal deformity. Spine. 2005;30(17 Suppl):S110-S117.

Thompson GH, Akbarnia BA, Kostial P, Poe-Kochert C, Armstrong DG, Roh J, et al. Comparison of single and dual growing rod techniques followed through definitive surgery: a preliminary study. Spine. 2005;30(18):2039-2044.

Yuan N, Fraire JA, Margetis MM, Skaggs DL, Tolo VT, Keens TG. The effect of scoliosis surgery on lung function in the immediate postoperative period. Spine. 2005;30(19):2182-2185.

Review Date:
4/6/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Osteoarthritis

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

In This Report

Highlights
Introduction
Causes
Symptoms
Conditions with Similar Sym...
Risk Factors
Diagnosis
Prognosis
Lifestyle Changes
Medications
Alternative and Complementa...
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Pain Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors work equally well for pain management, but both types of drugs increase the risk for heart attacks, according to an important report from the U.S. Agency for Healthcare Quality and Research.
The prescription NSAID diclofenac (Voltaren, Cataflam) may present a higher risk for heart attack than other NSAIDs, suggests a 2006 Journal of the American Medical Association study.
Standard osteoarthritis medications provide moderate pain relief for only 2 - 3 weeks, suggests a 2007 review in the European Journal of Pain.

Acupuncture

Acupuncture may be helpful for people with knee and hip osteoarthritis, according to several 2006 studies:

An Annals of Internal Medicine study of 1,007 people with chronic osteoarthritis knee pain indicated that patients who received acupuncture plus standard care had greater improvement than those who received only physical therapy and anti-inflammatory drugs.
An Arthritis and Rheumatism study of 3,663 patients with chronic osteoarthritis knee or hip pain suggested that acupuncture plus routine care can provide significant improvements in pain relief and quality of life. In both studies, the benefits of acupuncture were sustained for up to 6 months after treatment completion.

Exercise and Knee Osteoarthritis

Weight-bearing exercise (walking, jogging) neither prevents nor increases the risk of knee osteoarthritis in healthy middle-aged and elderly people, suggests a 2007 study in Arthritis and Rheumatism.

Risk of Hip Osteoarthritis

About 1 in 4 Americans can expect to develop osteoarthritis of the hip at some point in life, according to research presented at the 2006 American College of Rheumatology annual meeting. Body weight is a factor. People who are normal weight have a 20% risk, compared to those who are overweight (25%) or obese (39%).

Introduction

Osteoarthritis, also known as degenerative joint disease, is the most common form of arthritis. Scientists now believe osteoarthritis results from a combination of genetic abnormalities and joint injuries. In this disorder, an affected joint experiences a progressive loss of cartilage, the slippery material that cushions the ends of bones.

Osteoarthritis is a chronic disease of the joint cartilage and bone, often thought to result from "wear and tear" on a joint, although there are other causes such as congenital defects, trauma, and metabolic disorders. Joints appear larger, are stiff and painful, and usually feel worse with increased use throughout the day.

As a result, the bone beneath the cartilage undergoes changes that lead to bony overgrowth. The tissue that lines the joint can become inflamed, the ligaments can loosen, and the associated muscles can weaken. The patient experiences pain when using the joint. In addition to humans, nearly all vertebrates suffer from osteoarthritis, including porpoises and whales, as did long-extinct terrestrial travelers such as dinosaurs.

Click the icon to see an animation about osteoarthritis.

Joints are designed to provide flexibility, support, stability, and protection. These functions, essential for normal and painless movement, are primarily supplied by specific parts of the joint: the synovium and cartilage.

Synovium. The synovium is a membrane that surrounds the entire joint. It is filled with synovial fluid, a lubricating liquid that supplies nutrients and oxygen to cartilage.

Cartilage. The cartilage is a slippery tissue that coats the ends of the bones. Cartilage is one of the few tissues in the body that does not have its own blood supply. It has a number of essential components:

Click the icon to see an image of the synovial membrane and cartilage in the knee joint.

Chondrocytes. Chondrocytes, the basic cartilage cells, are critical for balance and function.
Water. Cartilage contains a high percentage of water, although it decreases with age. About 85% of cartilage is water in young people, and about 70% is water in older individuals.
Proteoglycans. These are large molecules that help make up cartilage. Their important value is their capacity to bond to water, which ensures the high-fluid content in cartilage.
Collagen. This is the critical protein in cartilage. It forms a mesh to give support and flexibility to the joint. Collagen is the main protein found in all the connective tissues of the body, including the muscles, ligaments, and tendons.

The combination of the collagen meshwork and the high water content, tightly bound by proteoglycans, creates a resilient and slippery pad in the joint, which resists the compression between bones during muscle movement. The synovial fluid lubricates and provides oxygen and nutrients to the bloodless cartilage.

Deterioration of Cartilage. Osteoarthritis develops when cartilage in a joint deteriorates. The process is usually slow.

In the early stages of the disease the surface of the cartilage, or even the synovium in some people, becomes inflamed and swollen. There is a loss of proteoglycan molecules and other tissue components that cause water loss. Fissures and pits appear in the cartilage.
As the disease progresses and more tissue is lost, the cartilage loses elasticity and fluid. It becomes increasingly prone to damage due to repetitive use and injury.
Eventually large amounts of cartilage are destroyed, leaving the ends of the bone within the joint unprotected.

To compound the process, bone around arthritic joints is not structurally normal. As the body tries to repair damage to the cartilage, problems can develop:

Clusters of damaged cells or fluid-filled cysts may form around the bony areas or near the fissures.
Fluid pockets may also form within the bone marrow itself, causing swelling. The marrow, which runs up through the center of bone, is rich in nerve fibers, and such injuries may be an important source of pain in many patients with osteoarthritis.
Bone cells may respond to damage by multiplying, growing, and forming dense, misshapen plates around exposed areas.
At the margins of the joint, the bone may produce outcroppings, on which new cartilage cells (chondrocytes) proliferate and grow abnormally.

Unlike some other types of arthritis, such as rheumatoid arthritis, osteoarthritis does not spread through the entire body. (In other words, it is not systemic.) Rather, it affects one or several joints. Osteoarthritis affects joints differently depending on their location in the body.

Osteoarthritis is commonly found in joints of the fingers, feet, knees, hips, and spine.
It sometimes occurs in the wrist, elbows, shoulders, and jaw, but is not common in these locations.

Causes

The biologic factors leading to the deterioration of cartilage in osteoarthritis are not entirely understood. Many experts believe that osteoarthritis results from a genetic susceptibility that causes some biologic response to injuries to the joint, which in turn leads to progressive deterioration of cartilage. In addition, the ability to make repairs becomes progressively limited as cartilage cells age.

Although osteoarthritis generally accompanies aging, osteoarthritic cartilage is chemically different from normal aged cartilage. As chondrocytes (the cells that make up cartilage) age, they lose their ability to make repairs and produce more cartilage. This process may play an important role in the development and progression of osteoarthritis.

Researchers report a high correlation of osteoarthritis between parents and children or between siblings. Genetic factors are thought to be involved in about half of osteoarthritis cases in the hands and hips and a somewhat lower percentage of cases in the knee. A number of genes are under investigation that might contribute to an inherited risk.

For example, mutations in the ank gene may be important in some cases. The ank gene regulates pyrophosphate, a chemical that inhibits the formation of mineral deposits, and may protect the cartilage in joints. Mutations in the ank gene then may result in lower pyrophosphate levels in the joint, leading to accumulation of mineral deposits and arthritis. (About 60% of people with osteoarthritis have mineral deposits in their cartilage.)

Another gene, called the osteoprotegerin gene, is important in regulating bone and cartilage formation. Mutations in this gene may play a role in osteoarthritis.

The inflammatory response is an overreaction of the immune system to an injury or other assault in the body, such as an infection. This response causes specific immune factors, called cytokines, to gather in injured areas and cause inflammation and damage to body tissue and cells. The inflammatory response plays an important role in rheumatoid arthritis and other muscle and joint problems associated with autoimmune diseases. It has generally been believed that inflammation plays at most a minor role in osteoarthritis and is more likely to be a result -- not a cause -- of the disease.

However, recent studies suggest that inflammation may play an important role in the progression of osteoarthritis and its chronic nature. For example, a 2003 study found evidence of severe inflammation in the lining of the joints in 30% of patients with osteoarthritis. Still, the effects of the inflammatory response in osteoarthritis are likely to be different from those in rheumatoid arthritis and less severe.

Some theories on how this response may contribute to osteoarthritis involve overproduction of enzymes called matrix metalloproteinases or MMPs (also called collagenases). In large amounts they break down collagen, the building blocks of cartilage. Some studies suggest that immune factors called vascular endothelial growth factor (VEGF) are overproduced during the inflammatory response and in turn increase production of MMPs.

Another theory suggests that the inflammatory response is triggered by the changes and injuries in the bone that occur during osteoarthritis. According to this theory, immune factors released in this process diffuse into the cartilage, where they suppress cartilage cell growth and activate MMPs.

Joint injuries are the starting point in the disease process. Osteoarthritis sometimes develops years after a single traumatic injury to or near a joint. One large study found that by age 65, osteoarthritis developed in almost 14% of those who had joint injuries as young adults, compared to just 6% in those without earlier injuries. Patients with knee injuries were five times more likely to have osteoarthritis in the injured knee than those without injuries, and patients with hip injuries were more than three times more likely to develop arthritis in the injured hip. Proper treatment of injuries, such as surgical repair of ligament tears in the knee with a strong rehabilitation approach, may help to prevent the development of osteoarthritis.

Other causes of osteoarthritis include:

Bleeding disorders such as hemophilia that cause bleeding to occur in the joint
Disorders such as avascular necrosis that block the blood supply near the joint
Complications of persistent, inflammatory arthritic conditions, particularly chronic gout, pseudogout, or rheumatoid arthritis
Conditions that cause iron build-up in the joints such as hemochromatosis

Symptoms

The pain of osteoarthritis typically begins gradually and progresses slowly over many years. People under age 40 may have the condition with no symptoms at all. Osteoarthritis is commonly identified by the following symptoms:

The most common symptom of osteoarthritis in any joint is pain that worsens during activity and gets better during rest. As the disease advances, the pain may occur even when the joint is at rest.
Pain is generally described as aching, stiffness, and loss of mobility.
The pain may behave like a roller coaster, with bad spells followed by periods of relative relief.
Pain seems to increase in humid weather.
Some people experience muscle spasm and contractions in the tendons.
Osteoarthritis in the knee may cause a crackling-like noise (called crepitus) when moved.

Hand. Osteoarthritis of the hand occurs most often in older women and may be inherited within families. The following joints are most frequently affected:

Distal interphalangeal (DIP) joint. The first joint below the fingertips is the most common location of osteoarthritis of the hand. These joints can develop bony growths known as Heberden's nodes.
Carpometacarpal (CMC) joint. The joint at the base of the thumb, where the thumb joint connects with the wrist, is the second most common location.
Proximal interphalangeal (PIP) joint. The middle joints of the fingers can also develop osteoarthritis. These joints may develop small, solid lumps (nodules) known as Bouchard's nodes.

Click the icon to see an image of osteoarthritis.

Recent studies suggest that osteoarthritis of the hand may predict the later development of osteoarthritis in the hip or knee. A 2005 study found that patients with hand osteoarthritis were three times more likely to develop hip arthritis. Osteoarthritis of the hand also slightly increased the risk for knee osteoarthritis.

Knee. Osteoarthritis is particularly debilitating in the weight-bearing joints of the knees. The joint is usually stable until the disease reaches an advanced stage when the knee becomes enlarged and swollen. Although painful, the arthritic knee usually retains reasonable flexibility.

Osteoarthritis can cause loss of cartilage in the knee. The meniscus, the cartilage pad between the joint formed by the thighbone and the shinbone, plays an important role in protecting the joint. It acts as a shock absorber. In knee surgery called meniscectomy, the doctor removes the damaged cartilage. However, a 2006 study suggested that preserving the meniscus, even if it is damaged, is better than removing it. Researchers showed that even a small amount of meniscus helps protect the joint and prevent osteoarthritis from worsening. Experts recommend that patients try lifestyle changes (exercise and weight loss), braces, and medication before undergoing knee surgery.

Click the icon to see an image of the knee joint.

Hips. About 1 in 4 people will develop hip arthritis over the course of their lifetime. Being obese increases the risk. Osteoarthritis frequently strikes the weight-bearing joints in one or both hips. Pain develops slowly, usually in the groin and on the outside of the hips, or sometimes in the buttocks. The pain also may radiate to the knee, confusing the diagnosis. Those with osteoarthritis of the hip often have a restricted range of motion (particularly when trying to rotate the hip) and walk with a limp, because they slightly turn the affected leg to avoid pain.

Click the icon to see an image of the hip joint.

Spine. Osteoarthritis may affect the cartilage in the disks that form cushions between the bones of the spine, the moving joints of the spine itself, or both. Osteoarthritis in any of these locations can cause pain, muscle spasms, and diminished mobility. In some cases, the nerves may become pinched, which also produces pain. Advanced disease may result in numbness and muscle weakness. Osteoarthritis of the spine is most troublesome when it occurs in the lower back or in the neck, where it can cause difficulty in swallowing.

Click the icon to see an image of the spine.

Shoulder. Osteoarthritis is less common in the shoulder area than in other joints, but it may develop in the shoulder joint (the glenohumeral joint). In such cases, it is most often associated with a previous injury, and patients gradually develop pain and stiffness in the back of the shoulder. Osteoarthritis also can develop in the acromioclavicular (AC) joint, which is between the shoulder blade and the collarbone. However, it rarely causes symptoms in this location.

Conditions with Similar Symptoms

Numerous conditions have symptoms of joint aches and pains. Something as benign as sleeping on a bad mattress to the serious afflictions associated with cancer can mirror symptoms of osteoarthritis. Other problems that can cause aches and pains in the joints include physical injuries, infections, tendinitis, and poor circulation. A number of rare genetic diseases attack the joints.

Osteoarthritis can generally be distinguished from other joint diseases by considering several factors together:

Osteoarthritis usually occurs in older people and is located in only one or a few joints
The joints are less inflamed than in other arthritic conditions
Progression of pain is usually gradual.

A few of the most common disorders that can be confused with, or may even accompany, osteoarthritis are discussed below.

Osteoarthritis may be confused with rheumatoid arthritis, particularly when osteoarthritis affects multiple joints in the body. Rheumatoid arthritis begins in the synovial membrane rather than the cartilage. It normally occurs earlier in life than osteoarthritis, often striking people in their 30s and 40s. Rheumatoid arthritis affects many joints, and often occurs symmetrically on both sides of the body. People generally have morning stiffness that lasts for at least an hour. (Stiffness from osteoarthritis usually clears up within half an hour.)

X-rays show changes in the bones that differ from those occurring in osteoarthritis. In rheumatoid arthritis, blood tests often show a specific antibody, known as rheumatoid factor, which is not present with osteoarthritis. In another blood test, levels of a factor called erythrocyte sedimentation rate (ESR) are often elevated in rheumatoid arthritis, but they are generally normal in osteoarthritis. Rheumatoid arthritis also does not usually show up in the fingertips where osteoarthritis is common.

Rheumatoid arthritis is a body-wide (systemic) autoimmune disease that initially attacks the synovium, a connective tissue membrane that lines the cavity between joints and secretes a lubricating fluid.

Click the icon to see an image of osteoarthritis vs. rheumatoid arthritis.

Chondrocalcinosis is a disease in which certain calcium crystals known as CPPD (calcium pyrophosphate dihydrate) are deposited in the joints. It affects about 25% of the population and can accompany and even worsen osteoarthritis. The problem has been called pseudogout or pseudo-osteoarthritis, in the latter case particularly when it affects the knees. A doctor can usually differentiate between the two disorders, however, because chondrocalcinosis usually damages other joints (such as wrists, elbows, and shoulders) that are not usually affected by osteoarthritis. The condition may explain why some patients with osteoarthritis receive benefit from colchicine, a drug used for gout and other crystal-induced joint diseases.

Charcot's joint occurs when an underlying disease, usually diabetes, causes nerve damage in the joint, which leads to swelling, bleeding, increased temperature, and changes in bone. There may be a loss of sensation that leads to an increased risk for injury from overuse.

Risk Factors

Osteoarthritis is the most common type of arthritis. In the U.S., about 12.1% of Americans (21 million people) age 25 and older have osteoarthritis. The prevalence in osteoarthritis increases as people age. Experts estimate that by 2030, 20% of Americans (72 million people) age 65 years and older will be at risk for developing osteoarthritis.

Before age 45, osteoarthritis occurs more frequently in males (although it is not common in younger adults). After age 55, it develops more often in females. In a 2000 study, 33% of women had osteoarthritis compared to 25% of men. Some research suggests that women may also experience greater muscle and joint pain, in general, than men. And, women also tend to be undertreated for pain compared to men. The causes of such differences in pain sensitivity and treatment are largely unknown and most likely are due to a complicated mix of biologic, psychologic, and social factors.

The incidence is highest in lower educational levels. In a 2000 study, 41% of adults with less than a high school education had arthritis compared to 21% of college graduates.

Although the average rate of osteoarthritis among older adults in the U.S. is 60%, it can vary widely in certain geographical regions. In the U.S., the rates in older adults are lowest (34%) in Hawaii and highest (70%) in Alabama. In general, the highest prevalence of arthritis in America occurs in the central and northwestern states.

The rate of osteoarthritis varies by ethnic group. In the U.S., Caucasians and African-Americans have higher rates of arthritis than Hispanics or other ethnic groups. Osteoarthritis also tends to favor specific joints over others in certain ethnic groups. The following are some examples:

Older African-American men are about 33% more likely than Caucasian men to have hip osteoarthritis. In one study, although men in both groups had equal risks for arthritic knees, African-American men were more likely to have arthritis in both knees and to have more severe cases. Although comparable disparities in knee arthritis were observed between African-American and Caucasian women, they might be explained by greater average weight among African-American women. The study could not account for the differences among men, however.
Asians appear to have a higher incidence of osteoarthritis in the knee, an equal risk for osteoarthritis in the spine, and a lower risk for osteoarthritis in the hips than Caucasians.

Genes that determine the angles, amount of force, and other structural factors in the hip joints, or genes that regulate the chemistry in the joints, may account for ethnic differences.

Some researchers suggest that a number of people have anatomical abnormalities, such as mismatched surfaces on the joints, which could be damaged over time by abnormal stress. Legs of unequal length or skewed feet can cause jerky movement and may cause osteoarthritis. One study reported that those whose knees bent inward ("knock-kneed") or outward ("bow-legged"), for example, were more likely to have progressive osteoarthritis of the knee.

Obesity, defined as being 20% over one's healthy weight, places people (particularly women) at increased risk for osteoarthritis. It also worsens osteoarthritis once deterioration begins. This higher risk is due to increased weight on the joints. However, being obese also increases the risk for osteoarthritis in the fingers as well as the knees and hips, suggesting that being overweight may contribute to osteoarthritis in other ways. Some research indicates that obesity may produce an inflammatory response, which is now a major suspect in age-related diseases -- not only osteoarthritis but also heart disease. [See In-Depth Report #53: Weight control and diet.]

Because injuries can trigger the disease process, people whose work or leisure activities place them at risk for muscle and joint injuries may face a higher risk for osteoarthritis later on.

Workers at Higher Risk. Certain occupations that require repeated stressful motions (such as squatting or kneeling with heavy lifting) can contribute to deterioration of cartilage. One study suggested that workers whose jobs require kneeling or squatting for more than an hour a day are at high risk for knee osteoarthritis. (In the study, jobs that involved heaving lifting, climbing stairs, or walking also posed some, but not as high, a risk. Being heavier compounded the chances for osteoarthritis.)

Exercise. There has been some question about the role of strenuous exercise in osteoarthritis. Sports that definitely pose a higher risk for osteoarthritis are those that require repetitive or direct joint impact (such as football), twisting, or both (baseball pitching, soccer).

Marathon runners, however, have a relatively low rate of osteoarthritis. Some scientists speculate that running enhances cartilage health because the rhythmical compression of cartilage expels wastes and promotes absorption of nutrients.

In any case, regular and moderate exercise is important for everyone and does not increase the risk for osteoarthritis. In fact, a 2006 study of middle-aged and elderly people found that recreational weight-bearing exercise (walking, jogging) neither protects against nor increases the risk for osteoarthritis. Furthermore, many factors associated with a sedentary life (muscle weakness, obesity) are associated with a higher risk for osteoarthritis.

Diagnosis

Osteoarthritis is often visible in x-rays. Cartilage loss is indicated by certain images:

If the normal space between the bones in a joint is narrowed.
If there is an abnormal increase in bone density.
If bony projections, cysts, or erosions are evident.
X-rays can also reveal any cysts that might develop in osteoarthritic joints. If other conditions are suspected or if the diagnosis is uncertain, additional tests are necessary.
An MRI may show evidence of osteoarthritis that x-rays miss.

X-rays are a form of electromagnetic radiation (like light); they are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel.

Blood test results may help diagnose or rule out osteoarthritis. Some examples include:

Elevated levels of rheumatoid factor (specific antibodies in the synovium) and so-called erythrocyte sedimentation rates (ESR or sed rate) indicate rheumatoid arthritis.
Hyaluronic acid (HA), a joint lubricant, is being tested as a potential biomarker for osteoarthritis. High levels of HA may indicate increased risk for osteoarthritis.
Elevated levels of a factor called C-reactive protein, which is produced by the liver in response to inflammation, are proving to be good predictors of osteoarthritic progression in the knee.

If the diagnosis is uncertain or infection is suspected, a doctor may attempt to withdraw synovial fluid from the joint using a needle. There will not be enough fluid to withdraw if the joint is normal. If the doctor can withdraw fluid, problems are likely, and the fluid will be tested for factors that might confirm or rule out osteoarthritis:

Cartilage cells in the fluid are signs of osteoarthritis.
A high white blood cell count is a sign of infection.
High uric acid in the fluid is an indication of gout.

Click the icon to see an animation on gout.

Other factors may be present that suggest different arthritic conditions, including Lyme disease and rheumatoid arthritis.
In people with known osteoarthritis, researchers may look for certain factors in synovial fluid (sulfated glycosaminoglycan, keratin sulfate, and link protein) that can suggest a more or less severe condition.

Prognosis

Osteoarthritis itself is not life-threatening, but a person's quality of life can significantly deteriorate from pain and loss of mobility. The negative effects on activities and physical and mental health are significant regardless of age, educational level, or gender. Only heart disease has a greater impact on work. Five percent of those who leave the work force do so because of osteoarthritis. Unless alleviated by medication or corrected by surgery, advanced osteoarthritis can force the patient to forgo even relatively low-impact activities, such as walking. No treatment can cure osteoarthritis, and none can alter its progression with certainty, but many available therapies can relieve symptoms and significantly improve the quality of life.

Lifestyle Changes

Many doctors suggest first trying lifestyle changes to reduce stress on affected joints. Physical therapy and supportive devices can be helpful. Intensive education on how to protect and care for an osteoarthritic joint may help patients avoid multiple visits to their doctor.

Once osteoarthritis has been diagnosed, patients should reduce shock to the affected joint. Hammering away at deteriorating cartilage is likely to speed up the degeneration. People in occupations requiring repetitive and stressful movement should explore ways to reduce trauma. Adjusting the work area or substituting tasks that produce less stress on joints helps reduce shock.

Joints require motion to stay healthy. Long periods of inactivity cause the arthritic joint to stiffen and the adjoining tissue to atrophy. A moderate exercise program that includes low-impact aerobics and power and strength training has benefits for osteoarthritic patients, even if exercise does not slow down the disease progression. Exercise helps:

Reduce stiffness and increase flexibility. It may also help improve the strength and elasticity of knee cartilage.
Promote weight loss.
Improve strength, which in turn improves balance and endurance.
Reduce stress and improve feelings of well being, which helps patients cope with the emotional burden of pain.

Exercise especially helps patients with mild-to-moderate osteoarthritis in the hip or in the knee. Many patients who begin an aerobic or resistance exercise program report less disability and pain. They are better able to perform daily chores and remain more independent than their inactive peers. Older patients and those with medical problems should always check with their doctor before embarking on an exercise program.

Three types of exercise are best for people with osteoarthritis:

Strengthening exercise
Range-of-motion exercise
Aerobic, or endurance, exercise

Strengthening Exercise. Strengthening exercises include isometric exercises (pushing or pulling against static resistance). Isometric training builds muscle strength while burning fat, helps maintain bone density, and improves digestion.

Some experts encourage patients to emphasize strengthening leg muscles as a first treatment step, before using pain relievers. Patients who rely on painkilling drugs may overuse knees, which do not have muscle tissue sufficiently strong enough to protect the joints from further damage. However, some studies suggest that building up thigh muscles may worsen osteoarthritis in people whose knees are misaligned (for instance those who are "bow-legged" or "knock-kneed"). Such individuals should check with a physical therapist for the best options. Strengthening the thigh muscles is certainly protective for people who have not yet developed osteoarthritis.

Exercise, such as weightlifting, helps build muscle that is usually lost with age and puts stress on bones, helping keep them strong and healthy.

Range-of-Motion Exercise. These exercises increase the amount of movement in a joint and muscle. In general, they are stretching exercises. The best examples are yoga and tai chi, which focus on flexibility, balance, and proper breathing. In one study, older adults who practiced the gentle movement, breathing, and meditation exercises of tai chi for 10 weeks reported less pain than their peers who did not learn the technique.

Click the icon to see an image of cholesterol.

Aerobic (Endurance) Exercise. These exercises help control weight and may reduce inflammation in some joints. Low-impact workouts also help stabilize and support the joint. Cycling and walking are beneficial, and swimming or exercising in water is highly recommended for people with arthritis. (Patients with osteoarthritis should avoid high-impact sports, such as jogging, tennis, and racquetball.)

Click the icon to see an image of exercise.

In addition to exercise, manipulation of muscles and joints by a trained therapist may be helpful. In one study, patients who had a combination of physical therapy and an exercise program reported 30 - 40% improvement after only two to four visits.

Overweight patients with osteoarthritis can lessen the shock on their joints by losing weight. Knees, for example, sustain an impact three to five times the body weight when descending stairs. Losing 5 pounds of weight can eliminate 20 pounds of stress on the knee. The greater the weight loss, the greater the benefit. [See In-Depth Report #53:Weight loss and diet.]

Plant Chemicals. A large study reported significant improvement in symptoms when patients took extracts from avocados and soybeans called saponins. Another study noted that although these substances did not relieve hip pain, they did slow progression of joint deterioration. Soy has chemicals called isoflavones that may have additional benefits, such as preventing bone loss.

Fish Oil and Omega-3 Fatty Acids. Omega-3 fatty acids, which are found in fish oil, canola oil, black currant or primrose seed oils, and flax seeds, have anti-inflammatory properties and may help protect against cartilage deterioration. Supplements of omega-3 fatty acids, such as docosahexaenoic (DHA) and eicosapentaneoic (EPA) acids that are found in fish oil, are available.

Vitamin B3 (Niacin). Some research suggests that vitamin B3 may have some benefits for people with osteoarthritis.

Click the icon to see an image of the benefits of vitamin B3.

Click the icon to see an image of the sources of vitamin B3.

Calcium and Vitamin D. Calcium and vitamin D are important for strong bones. Although osteoarthritis is primarily a disease of joints, bone strength is also important, particularly in older people.

Click the icon to see an image of osteoporosis.

Many experts now recommend 1,000 mg of calcium a day for most adults and 1,200 - 1,500 mg for adolescents. Pregnant women, postmenopausal women not on estrogen therapy, and those on corticosteroids should get 1,500 mg per day; breast feeding women should get 2,000 mg/day. Because calcium supplements increase the risk for kidney stones, an upper limit of 2,500 mg is recommended.

Current guidelines recommend 400 IU of vitamin D per day and 600 IU per day after age 60. Lack of sunlight and unhealthy diets contribute to deficiencies in vitamin D. Good dietary sources include fortified milk, sardines, herring, salmon, tuna, liver, dairy products, and egg yolks. Although supplements are often necessary, vitamin D can be toxic in high doses, and no one should take more than 1,200 IU per day.

Selenium. Selenium is a trace mineral found in grains, nuts, vegetables, and some meats and seafood. Preliminary research suggests that people who do not get enough selenium in their diet may be more likely to develop knee osteoarthritis. Researchers are investigating whether selenium supplements may help protect against osteoarthritis and prevent it from worsening.

Ice. When a joint is inflamed (particularly in the knee) applying ice for 20 - 30 minutes can be effective. If an ice pack is not available, a package of frozen vegetables works just as well.

Heat Treatments. Patients afflicted with osteoarthritis of the hands can relieve pain with hot soaks and warm paraffin application. Osteoarthritis of the hip can be treated with heating pads.

Interestingly, moving to a warm climate does not seem to make much difference. According to one study, people who live in warmer places are actually more sensitive to small shifts in temperature than people who live in cold damp climates, and they experience pain as readily as their northern peers do in response to larger temperature shifts.

A wide variety of devices are available to help support and protect joints:

Splints or braces, worn while the joint is at rest or in use, help align joints and properly distribute weight. They are used most frequently to treat arthritic hands, wrists, knees, ankles, and feet. Many of these devices allow some movement within the affected joint and do not restrict nearby joints. They are usually made from lightweight metal, leather, elastic, foam, and moldable plastic with easy-to-use Velcro straps. Any brace, splint, or other device for joint protection should be custom-fitted by a physical or occupational therapist, or an orthotist. Poorly fitting or improperly used orthoses can cause more harm than good.
Using elastic supports on affected joints may benefit some people. For example, in one study, wearing insoles plus elastic straps supporting the ankle joint helped overweight women with osteoarthritis in the knee. It is important to consult with a doctor about how to use elastic supports.
Wrapping the knee with special therapeutic tape that provides support to specific parts of the joint may be effective. In one trial, patients experienced a 40% reduction in pain within a few days. They wore the tape for 3 weeks, and pain relief continued for 3 more weeks following treatment. The tape should be applied by physical therapists or other trained health professionals. Longer-term studies are needed to determine any continuous benefits.
Wearing shock-absorbing soles in shoes or orthopedic shoes can help in daily activities and during gentle exercise. Heel wedges in the shoes can sometimes help patients avoid knee replacement surgery.
A neck brace or corset may relieve back pain.
A firm mattress also often proves beneficial.
In extreme cases of back pain, lying in traction might be necessary.
Canes, crutches, or walkers offer benefits to patients with advanced arthritis.
Specially designed hip protectors, worn under the clothes, can also protect against hip fractures in elderly patients with impaired mobility who are apt to fall.

Medications

Many medications are available for relieving the symptoms of osteoarthritis. A major analysis indicated that drug therapy is generally more effective than non-drug treatments (surgery, acupuncture). However, a 2006 review of knee osteoarthritis studies found that pain-relief medications generally help only for the first 2 - 3 weeks of treatment. The following are some of the medications used in mild-to-severe cases:

Acetaminophen
Nonsteroidal anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors
Capsaicin
Tramadol
Narcotic pain relievers (oxycodone, oxymorphone, or morphine)
Glucosamine and chondroitin (see Alternative and Complementary Medicine section)

Acetaminophen (Tylenol, Anacin-3, Panadal, Phenaphen, Valadol, and others) is currently the first choice for treating osteoarthritis. However, several major analyses report that acetaminophen is less effective than NSAIDs in reducing moderate-to-severe pain. Because acetaminophen has fewer side effects, most experts suggest trying this drug first, then switching to an NSAID if acetaminophen does not provide sufficient pain relief.

Side Effects. Acetaminophen is inexpensive and generally safe. It poses far less of a risk for gastrointestinal problems than NSAIDs and does not appear to increase the risk for miscarriage (as NSAIDs do), even when used regularly.

It does have some adverse effects, however, and the daily dose should not exceed 4 grams (4,000 mg). Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly.

The kidneys are responsible for removing wastes from the body, regulating electrolyte balance and blood pressure, and the stimulation of red blood cell production.

Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. There are dozens of NSAIDs:

Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve, Naprosyn), ketoprofen (Actron, Orudis KT).
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren, Cataflam), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), dexibuprofen (Seractil), indomethacin (Indocin), meloxicam (Mobic, generic).
Topical NSAIDs delivered in gels, creams, or patches do not appear to provide any long-term benefits in reducing arthritic pain. A review of clinical trial data, published in 2004, suggested that guidelines that recommend topical NSAIDs for treatment of osteoarthritis should be revised.

Many experts now recommend that patients use oral NSAIDs for only a short period of time. A 2004 review, published in the British Medical Journal, suggested that long-term use of NSAIDs does not actually reduce osteoarthritis pain and may increase patients’ risk of experiencing side effects. High dosages of NSAIDs can cause heart problems (such as increased blood pressure), kidney problems, and stomach bleeding.

In April 2005, the Food and Drug Administration (FDA) asked drug manufacturers of prescription NSAIDs to include with their products the same boxed warning used for the COX-2 inhibitor celecoxib (Celebrex). This boxed warning emphasizes an increased risk for cardiovascular events and gastrointestinal bleeding in people taking these drugs. The FDA also requested manufacturers of over-the-counter NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and gastrointestinal risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions.

A 2006 comprehensive report from the U.S. Agency for Healthcare Quality and Research indicated that both NSAIDs and COX-2 inhibitors are equally effective for pain relief and pose similar risks for heart attacks. The report found that one particular NSAID, naproxen (Aleve, Naprosyn), presents less risk of heart attack for some patients. A 2006 Journal of the American Medical Association study suggested that diclofenac (Voltaren, Cataflam) may pose a higher risk for heart attack than other NSAIDs. All patients should talk to their doctors before switching any medications.

Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers, and the rate of NSAID-caused ulcers is increasing. Such ulcers are also more likely to bleed than those caused by the bacteria H. pylori. NSAID-related bleeding and stomach problems may be responsible for 107,000 hospital admissions and 16,500 deaths each year. Because there are usually no gastrointestinal symptoms from NSAIDs until bleeding begins, doctors cannot predict which patients taking these drugs will develop bleeding.

Among the groups at high risk for bleeding are elderly people, anyone with a history of ulcers of GI bleeding, patients with serious heart conditions, alcohol abusers, and those on certain medications, such anticoagulants ("blood thinners"), corticosteroids, or bisphosphonates (drugs used for osteoporosis). Proton-pump inhibitors may help to prevent and heal ulcers caused by NSAIDs. Proton-pump inhibitors include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid)

Click the icon to see an image of a gastric ulcer.

Drugs for Prevention NSAID-Induced Ulcers. If you have NSAID-induced ulcers, follow these steps:

Switch to alternative pain relievers. This is the first step in preventing or healing ulcers caused by NSAIDs. If people cannot change drugs, they should use the lowest NSAID dose possible.
Try proton-pump inhibitors (PPIs). These drugs help reduce NSAID-ulcer rates by as much as 80% compared with no treatment. Brands include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).
Try misoprostol or Arthrotec. If other drugs are inappropriate, misoprostol protects against the major intestinal toxicity of NSAIDs. It was the first drug approved for preventing NSAID-induced ulcers. It is equally, or even more, effective than some of the PPIs, but it does not heal existing ulcers and has more side effects than PPIs. Patients tend to stop using it. Arthrotec is a combination of an ulcer protective drug called misoprostol and the NSAID diclofenac. One study found that patients taking Arthrotec had 65 - 80% fewer ulcers than those who took NSAIDs alone.

Healing Existing Ulcers. A number of drugs are available to heal NSAID-induced ulcers. Treatment takes about 2 - 6 weeks. Proton-pump inhibitors are the most effective drugs. Others that may be beneficial include sucralfate or H2 blockers, such as famotidine (Pepcid AC), cimetidine (Tagamet), ranitidine (Zantac).

Coxibs inhibit an inflammation-promoting enzyme called COX-2. This drug class was initially thought to provide benefits equal to NSAIDs but cause less gastrointestinal distress. However, following numerous reports of cardiovascular events, as well as skin rashes and other adverse effects, the FDA has been re-evaluating the relative risks and benefits of this drug class. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the United States market. Celecoxib (Celebrex) is still available, but patients should discuss with their doctors whether this drug is appropriate and safe for them.

A newer COX-2 inhibitor, etoricoxib (Arcoxia) is approved in 60 countries but not the United States. A 2006 Lancet study indicated that etoricoxib is similar to the NSAID diclofenac in risks for heart attack and stroke. (However, diclofenac has already been shown to have a higher risk of heart attack than any other NSAID, so some experts do not find this study result reassuring.) Etoricoxib caused more high blood pressure and fluid retention (edema) than diclofenac. Etoricoxib appeared to pose a lower risk than diclofenac for uncomplicated upper gastrointestinal problems, (obstruction, perforation, bleeding, ulcers), but there was little difference between the two drugs for more serious gastrointestinal complications. In 2007, the FDA rejected an application to market etoricoxib in the U.S.

Capsaicin is a component of hot red peppers and may bring pain relief when used as a skin cream (Zostrix). This is the only skin preparation that does more than just mask pain or reduce it temporarily. Capsaicin seems to reduce a substance in the body, known as substance P, which contributes both to inflammation and the delivery of pain impulses from the central nervous system. A small amount of capsaicin must be applied to the area of inflammation about four times a day. During the first few days of use, the patient will experience a warm, stinging sensation when the cream is applied. This sensation goes away, and pain relief usually begins within 1 - 2 weeks.

Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available and provides more rapid pain relief than tramadol alone with more long-lasting benefits than acetaminophen. Side effects are the same as for each of these drugs.

Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of moderate to severe pain. There are two types of narcotics:

Opiates, which are derived from natural opium (morphine and codeine).
Opioids, which are synthetic drugs. They include oxycodone (Percodan, Percocet, Roxicodone, Oxycontin), hydrocodone (Vicodin), oxymorphone (Numorphan), and fentanyl (Duragesic).

Although the use of narcotics for arthritic pain is controversial, many studies have suggested that they are rarely addictive for pain sufferers except among patients with a history of substance abuse. Some experts believe that opioids have a place in osteoarthritis treatment when milder drugs are not effective or appropriate. For example, a 2006 study suggested that a fentanyl skin patch may offer pain relief and improved function to some patients with severe knee or hip osteoarthritis who have not been helped by, or who cannot tolerate, NSAIDs or weaker opioids.

The use of such drugs may be beneficial when included as part of a comprehensive pain management program. Such a program involves screening prospective patients for possible drug abuse and then regularly monitoring those who are taking it, adjusting the dose as necessary to achieve an acceptable balance between pain relief and side effects. Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Unfortunately, opioid abuse among young people is a major concern.

When pain becomes a major problem and less potent pain relievers are ineffective, doctors may resort to corticosteroid (steroid) injections, usually by administering a shot into the affected joint every 3 months. Corticosteroid shots are useful only if inflammation is present in the joint. Relief from pain and inflammation is of short duration, and this treatment is rarely used for chronic osteoarthritis. These drugs may not be as effective for women as for men.

Corticosteroids mask pain, and the patient must be very careful to avoid over-use of the affected joints. Patients are usually advised not to have more than two or three injections a year, since there is some concern that repeated injections over the long term may be harmful. A reassuring study found no greater disease progression in people who had injections every 3 months for 2 years compared to those who were given sham injections on the same schedule. Because long-term use of corticosteroids has many potentially serious side effects, steroid medications are never given orally or systemically for the treatment of osteoarthritis.

Injections of hyaluronic acid (Hyalgan, Synvisc, Artzal, Nuflexxa) into the joint -- a procedure called viscosupplementation -- is now recommended as one of the treatments for osteoarthritis. Hyaluronic acid is a naturally occurring substance in joints that acts as a lubricant for slow movements and a shock absorber for fast motions. In high amounts, it also may have anti-inflammatory effects.

Patients receive a series of three to five injections once a week.
The drug is injected into the joint.
A health care worker will apply local anesthetic because these viscous (sticky) injections require a large needle.
Patients need to avoid weight-bearing activities for about 48 hours after each shot.

Hyaluronic injections appear to be about as effective as NSAIDs and corticosteroid injections for relieving pain, at least in men, and they have no adverse effects in the stomach or intestines. One study reported that between 39 - 56% of patients were at least nearly free of weight-bearing pain up to 24 weeks after the final injection. In another study, response was judged better or much better for 87% of knees after a second course, which was administered about 8 months later. Nevertheless, a number of studies on viscosupplementation have shown little or no benefits, particularly in women, and more research is needed to determine if they are useful. Injections are also expensive. Accurate placement of the needle directly into the knee joint space is important and may be difficult, even for experienced doctors, if there is no fluid build-up in the joint. Best success rates are with a specific approach into the kneecap called the lateral midpatellar.

Side Effects. Serious adverse reactions are rare. The most common side effects, pain at the injection site and knee pain and swelling, are usually mild and temporary. More research is needed to confirm benefits and long-term risks.

Researchers are studying various drugs that may provide pain relief or stop the disease process itself:

Bisphosphonates such as alendronate (Fosamax) and risedronate (Actonel) help prevent bone loss in people with osteoporosis. They are currently being investigated for osteoarthritis as well. A 2005 study reported that risedronate may delay joint destruction in patients with knee osteoarthritis.
Lidocaine, a local anesthetic, is available in patch form (Lidoderm) and has been used specifically for herpes zoster pain. Early studies indicate that it may provide significant pain relief for osteoarthritis.
Tetracycline antibiotics, such as doxycycline, may have a role to play in treating osteoarthritis. At low concentrations, the drug reduces the production of collagenases, which are enzymes critical to disease development and progression. Initial results from clinical trials suggest that doxycycline may help delay joint space narrowing.
Licofelone is a drug that inhibits both the COX enzyme plus an inflammatory substance called lipoxygenase 5. Early trials indicate it may be effective and safer than either NSAIDs or COX-2 inhibitors.
Diacerein inhibits an inflammatory substance in arthritic joints called interleukin-1b. It has shown promise in clinical trials. A 2006 review indicated that diacerein may be slightly better than NSAIDs for pain relief.
Botulinum toxin type A (Botox) injections may provide sustained pain relief for patients with knee osteoarthritis according to research presented at the 2006 American College of Rheumatology annual meeting.
Nitric oxide increases blood flow in the mucous lining and secretions of mucus and bicarbonate. Combining nitric oxide with NSAIDs may reduce the adverse effects on the gastrointestinal tract.
Trials of gene therapies that either fight joint degradation or strengthen cartilage are in very early stages.

Alternative and Complementary Medicine

Glucosamine hydrochloride and chondroitin sulfate are natural substances that are part of the building blocks found in and around cartilage. Extracts have been used in Europe for more than a decade to reduce pain and improve mobility in patients with osteoarthritis. For many years, researchers in the U.S. have been studying whether these dietary supplements really work for relieving osteoarthritis pain.

In 2006, the New England Journal of Medicine published the results from a major trial sponsored by the U.S. National Institutes of Health. Researchers compared the effects of glucosamine and chondroitin, alone and in combination, with the COX-2 inhibitor celecoxib (Celebrex) in nearly 1,600 patients with knee osteoarthritis. The dietary supplements were also compared with placebo (an inactive substance). Patients took the assigned substance once a day for 6 months.

The results indicated that, for most patients, neither glucosamine nor chondroitin were better than placebo in relieving knee pain. However, for patients with moderate-to-severe pain, a combination of glucosamine and chondroitin was significantly more effective than the other remedies. Celebrex worked best for patients with mild pain.

The next stage of the study will evaluate whether glucosamine and chondroitin, alone and in combination, can halt the progression of knee osteoarthritis.

Research presented at the 2006 American College of Rheumatology annual meeting suggested that chondroitin may prevent joint narrowing in patients with knee osteoarthritis.

Dosage. There are no current standard recommended dosages. Patients in the GAIT trial took 1,500 mg of glucosamine and 1,200 mg of chondroitin.

Side Effects. The safety records of both substances appear excellent. Long-term effects are still unknown, but studies of up to 3 years have reported no significant side effects. However, there are some concerns that glucosamine may affect insulin and blood sugar (glucose) metabolism. Patients with diabetes should not take glucosamine without first talking to their doctors.

Oral Enzymes. People in Europe have used natural enzymes -- including bromelain, trypsin, papain, and rutin -- to treat arthritic pain. Such enzymes have been marketed alone and in combinations (Wobenzym, Phlogenzym). They are not painkillers, and any benefits derived from them may take several weeks.

Ginger (Zingiberaceae). A 2001 study of patients with knee arthritis found that an extract of ginger reduced pain while standing and after walking. By using ginger, patients were able to reduce their pain medications after 6 weeks. Side effects included mild digestive upset.

S-adenosylmethionine (SAMe). S-adenosylmethionine (SAMe, pronounced "Sammy") is a synthetic form of a natural byproduct of the amino acid methionine. It has been marketed as a remedy for both depression and arthritis. Some research suggests that it may work as well as NSAIDs for short-term treatment of osteoarthritis. Other studies suggest that it may help rebuild damaged cartilage.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Acupuncture is being increasingly used to reduce osteoarthritis pain. The technique is painless and involves the insertion of small fine needles at select points in the body. Several study reviews have found that acupuncture provides at least short-term pain relief for osteoarthritis of the knee. Other studies have suggested that acupuncture’s benefits are mainly due to a strong placebo effect, or to the psychologically beneficial effects of close contact with health care providers.

In 2004, researchers published results from an important clinical trial that studied the effects of acupuncture on nearly 600 people with osteoarthritis of the knee. The results indicated that acupuncture can relieve pain and improve function. Several 2006 studies of thousands of patients with chronic osteoarthritis pain compared acupuncture to conventional treatment (physical therapy, anti-inflammatory drugs). These studies showed positive results and suggested that acupuncture’s benefits may be sustained for up to 6 months after treatment. In any case, acupuncture appears to be a safe and beneficial addition to standard therapy for certain patients, such as pregnant women, who cannot take most pain medications.

Acupuncture, hypnosis, and biofeedback are all alternative ways to control pain. Acupuncture involves the insertion of tiny sterile needles, slightly thicker than a human hair, at specific points on the body.

Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress pain. Patients are barely aware of the sensation. According to one study, the optimal treatment length is 40 minutes. A variant (sometimes called percutaneous electrical nerve stimulation, or PENS) applies these pulses through a small needle to acupuncture points. A review of trials reported that both methods were better than placebo (sham treatments) in treating osteoarthritis of the knee, although additional well-designed studies are needed.

Low-level laser therapy (LLLT) generates extremely pure light in a single wavelength. It does not produce heat and is painless. Some researchers are combining LLLT with transcutaneous electric nerve stimulation (TENS). Studies report widely varying results, with some showing significant reductions in pain and others reporting no effect. The differences may be due to different approaches, and standardized methods are needed to determine any benefits.

Hydrotherapy, also called spa therapy or balneotherapy, is an ancient therapy that uses bathing in mineral baths for soothing pain. Although many studies report positive results, including improved quality of life, very few have been rigorously conducted. A major analysis reported weak evidence on any real effect on pain or quality of life, but some patients may find comfort from this pleasant therapy.

Surgery

Different surgical procedures are available as a final measure to relieve pain and increase function in patients with osteoarthritis. Certain surgical procedures can help relieve pain if medications fail. Even with these procedures, however, joint replacement may still be needed later on.

Arthroscopy is performed to clean out bone and cartilage fragments that, in theory at least, may cause pain and inflammation. More than 650,000 of these procedures are done on arthritic knees each year in the U.S., and about half of patients report less pain after the procedure.

A rigorous 2002 trial, however, found that arthroscopic knee surgery was no more effective than sham surgery, (in which surgeons only pretended to operate on the knee), for relief of osteoarthritic pain or stiffness. The study, which followed patients at a Veterans Affairs hospital for 2 years, has called into serious question whether the popular procedure has any real benefits for osteoarthritis beyond what might be achieved by a placebo response. Research and debate continues on whether arthroscopy provides true benefits for those with osteoarthritis and, if so, which patients it may most help.

Click the icon to see an illustrated series detailing knee arthroscopy surgery.

When osteoarthritis becomes so severe that pain and immobility make normal functioning impossible, many people become candidates for artificial (prosthetic) joint implants using a procedure called arthroplasty. Hip replacement is the most established and successful replacement procedure, followed by knee replacement. Knee replacement, in fact, has a slightly better long-term success rate than hip replacement. Other joint surgeries (shoulders, elbows, wrists, fingers) are less common, and some arthritic joints (in the spine, for instance) cannot yet be treated in this manner. When two joints, such as both knees, need to be replaced, having the operations done sequentially rather than at the same time may result in fewer complications.

Click the icon to see an illustrated series detailing knee joint replacement surgery.

Candidates. The primary indications for surgery are pain and significant limitations of movement, including walking, that cannot be treated by less invasive therapies. Some experts suggest, however, that joint replacement should be considered earlier rather than as a last resort. They argue that patients who wait until they are severely disabled do not recover as completely as those who have the procedure earlier.

Patients who may not be good candidates are those with the following conditions:

Severe neurologic, emotional, or mental disorders
Severe osteoporosis
Other chronic medical conditions
Obesity

Surgeons often prefer to delay prosthetic implantation in younger patients, because implants wear out and they will require at least one revision procedure later on. Newer, more long-lasting materials, however, may help reduce the rate of re-operations.

Procedure Description. Although the following is mostly a description of hip replacement surgery, the principles are similar for other arthroplasties.

The surgeon removes the ball and socket joint that joins the pelvis and thigh bone (femur) and replaces it with an artificial joint (a prosthesis). It is composed of two pieces:

A cup-like device fits in the hip socket (called the acetabula), which has been hollowed out. This ball-and-socket cup is positioned to form the new joint.
A metal shaft, or stem, with a polished metal ball at the top, is inserted into the narrow center of the femur.

The prosthesis is usually made of a metal alloy and plastic. A ceramic implant may prove to last longer than other materials and be a safe option for younger patients.

There are different options available for attaching it to the adjoining bones:

A cement made of polymethylmethacrylate (usually preferred for older patients who generally have thinner bones).
So-called cementless implants, in which the prosthesis is coated with a porous material that allows bone to grow into and eventually adhere to the device. These implants are usually used for patients younger than age 65, who are likely to need repeat surgery in their lifetime.

Click the icon to see an illustrated series detailing hip joint replacement surgery.

Complications. Complications can occur, and, although uncommon, some can be life-threatening. There is a 1% chance of death within 3 months of an initial procedure and a 2.6% risk after a repeat procedure. The risks are highest in the first 3 months. Those at highest risks for complications are elderly adults, men (compared to women), African-Americans, and those with serious medical conditions.

Specific complications include the following:

Deep blood clots (known as deep vein thrombosis) and pulmonary embolism. Deep blood clots can develop in the legs after this surgery. This poses a very small risk (0.9%) for pulmonary embolism -- a dangerous condition in which the clot travels to the lungs. Anticoagulants (blood thinners) are important for preventing blood clots. These drugs include warfarin and low-molecular weight heparin. Anticoagulant therapy is given during the hospital stay and continued for several weeks at home. The patient also wears specially fitted elastic stockings to help prevent clots. Patients who are overweight are at higher than average risk for post-operative blood clots
Infection. Wound infection occurs in about 0.2% of joint replacements and requires prompt removal of the implant to treat the infection. A new prosthesis must be re-implanted at a later time. Any pre-existing infection must be treated and cured before surgery is performed. (Older women should be aware of urinary tract infections, which may require postponing surgery.) After surgery, patients should take certain precautions. For example, they should take antibiotics before invasive dental procedures or other surgery because bacteria can be introduced into the bloodstream and infect the areas around the artificial joints.
Hip dislocation. Occurs in about 3.1% of first hip procedures. The rate is much higher (14.4%) in revision operations.

Click the icon to see an image of a dislocated hip.

Pain. Thigh pain can occur after hip replacement. Porous hip prostheses are more likely to produce thigh pain than cement implants, although advanced techniques using a tapered shaft are reducing this complication.
Failure. The primary reason for implant failure is osteolysis (bone destruction) caused by long-term wear. The main source of wear is from tiny particles released from the prosthesis.
Other complications. These include uneven leg lengths, nerve damage that can cause numbness or weakness, urinary tract infections, delayed healing, and allergic reactions to the metal. Long-term, there have been rare reports of a possible autoimmune response, in which loose particles released from the prosthetic device trick certain immune system factors into attacking healthy cells. Any incidence of unexplained weight loss and fatigue may be symptoms of this uncommon event.

Rehabilitation. Aside from the surgeon's skill and the patient's underlying condition, the success rate depends on the kind and degree of activity the joint receives following replacement surgery.

The patient is urged and aided into getting out of bed and walking the day after surgery. Most hip replacement patients leave the hospital within a week and can walk with crutches within 2 - 4 weeks, recovering fully in about 3 months.

Physical therapy takes about 6 weeks to rebuild adjoining muscle and strengthen surrounding ligaments. Studies suggest that an exercise program started before surgery and resumed afterward can improve recovery. Continuous passive motion (CPM) is an effective regimen for knee replacement patients. It uses a mechanical device that slowly moves the joint through an arc of motion for an extended period of time. It is used to prevent scar tissue from developing. In one review, a combination of physical therapy and CPM were more beneficial than physical therapy alone.

Limitations After Surgery. While many patients find that joint replacement provides remarkable pain relief and restores some mobility, they need time to adjust to the artificial joint.

Limitations after hip surgery include:

Usually patients with new hips are able to walk several miles a day and climb stairs, but they cannot run.
Prosthetic hips should not be flexed beyond 90 degrees, so patients must learn new ways to perform activities requiring bending down (like tying a shoe).

Limitations after knee surgery include:

Walking distance improves in 80% of patients after knee replacement surgery, but patients still cannot run.
Only slightly more than half of patients report improvement in stair climbing. (Artificial knee joints generally have a range of motion of just 110 degrees.)

Failure Rates. Infection is a major cause of early failure and always requires revision. Improper balancing of the ligaments and other tissues surrounding the joint and resulting poor joint stability is also a common reason for failure of arthroplasties. Surgical expertise is important for avoiding this complication.

Older cement prostheses have a particularly high rate of bone loss and loosening due to cement deterioration. In general, studies report reoperation rates of over 30% after 10 years. Fortunately, advances in cement and prosthetic implants are improving the implant survival rates and reducing the need for revision procedures.

Uncemented arthroplasty using porous material has shown good results for the hip, although it may be less successful for knee replacement. In spite of short-term success, longer experience with this method suggests it may not be superior to cement prostheses. Failure of bone to grow into the porous material is a relatively common event, a problem that does not occur with cement prostheses. Some experts recommend cement implants over cementless ones for total knee arthroplasty.

A repair procedure called arthroplasty revision may be used in cases where the original transplant fails. The specific procedure depends on whether the bone defects that occurred are contained or uncontained.

Contained defects can be repaired with small bone grafts, the use of cement, or oversized cementless implants as required.
Uncontained defects are more severe and may require a large bone graft or specially constructed implants to restore bone.

If a second arthroplasty is required, the potential for complications is magnified: more bone is cut, more blood is lost, and the operation takes longer. Patients are also generally older and more vulnerable to complications.

Resection Arthroplasty. In resection arthroplasty, a false joint of scar tissue is created. This procedure is used most often in treating arthritis of the foot.

Osteotomy. If only a certain section (the medial compartment) of the knee is damaged and deformed by osteoarthritis, the surgeon may choose to perform osteotomy:

A surgeon opens the knee.
The surgeon performs a debridement (removal of damaged tissue) in the joint to eliminate the loose or torn fragments that are causing pain and inflammation.
The bone is then reshaped to remove the deformity.
The procedure may ease symptoms and slow disease progression. It is best used in heavier adults who are under 60 years old.

Hemicallotasis. Hemicallotasis is a procedure for the knee that may be a less invasive alternative to osteotomy. The surgeon attaches the knee with pins to an external frame-like device that lengthens the deformed part of the knee over several weeks. The patient is mobile during this period. Infections at the pin site are the most common complications.

Arthrodesis. If the affected joint cannot be replaced, surgeons can perform a procedure called arthrodesis that eliminates pain by fusing the bones together. The patient must understand, however, that fusing the bones makes movement of the joint impossible. Bone fusion is most often done in the spine and in the small joints of the hands and feet.

Unicompartmental Knee Arthroplasty. Unicompartmental knee arthroplasty (also called unicondylar knee arthroplasty) may be a useful procedure in cases of limited knee damage. It is recommended for relatively sedentary patients who are 60 years or older and not obese. It may relieve pain and delay the need for a total knee replacement. The procedure involves a small incision and insertion of small implants. It retains important knee ligaments, which preserve more movement than a total knee replacement.

Cartilage Transplants. Autologous chondrocyte implantation, also called chondroplasty or the Carticel approach, is used for knees damaged by injuries. In this procedure, arthroscopy is used to first remove cartilage in eroded areas. The results have been good to excellent, although long-term benefits are questionable. Whether it has any benefit for older patients with osteoarthritis is not yet known. Other cartilage transplant procedures are also under study.

Hip Resurfacing. Hip resurfacing is a surgical alternative to total hip replacement. It involves scraping the surfaces of the hip joint and femur and placing a metal cap over the bone. The procedure preserves much of the bone, so that a standard hip replacement can be done years later if needed. It may provide more stability, a faster recovery, and greater range of motion, making it a potentially good option for young, physically active patients.

Resources

www.rheumatology.org -- American College of Rheumatology
www.arthritis.org -- Arthritis Foundation
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.aaos.org -- American Academy of Orthopaedic Surgeons
www.fda.gov/cder/drug/infopage/cox2 -- FDA NSAID and COX-2 Inhibitor Information

References

Bjordal JM, Klovning A, Ljunggren AE, Slordal L. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials. Eur J Pain. 2007 Feb;11(2):125-38.

Cannon CP, Curtis SP, FitzGerald GA, Krum H, Kaur A, Bolognese JA, et al. Cardiovascular outcomes with etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomised comparison. Lancet. 2006 Nov 18;368(9549):1771-81.

Chou R, Helfland M, Peterson K, Dana T, Roberts C. Comparative Effectiveness and Safety of Analgesics for Osteoarthritis. Comparative Effectiveness Review No. 4. (Prepared by the Oregon Evidence-based Practice Center under Contract No. 290-02-0024.) Rockville, MD: Agency for Healthcare Quality and Research. September 2006.

Felson DT, Niu J, Clancy M, Sack B, Aliabadi P, Zhang Y. Effect of recreational physical activities on the development of knee osteoarthritis in older adults of different weights: the Framingham Study. Arthritis Rheum. 2007 Feb 15;57(1):6-12.

Laine L, Curtis SP, Cryer B, Kaur A, Cannon CP; MEDAL Steering Committee. Assessment of upper gastrointestinal safety of etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomized comparison. Lancet. 2007 Feb 10;369(9560):465-73.

Langford R, McKenna F, Ratcliffe S, Vojtassak J, Richarz U. Transdermal fentanyl for improvement of pain and functioning in osteoarthritis: a randomized, placebo-controlled trial. Arthritis Rheum. 2006 Jun;54(6):1829-37.

McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase2. JAMA. 2006 Oct 4;296(13):1633-44.

Rintelen B, Neumann K, Leeb BF. A meta-analysis of controlled clinical studies with diacerein in the treatment of osteoarthritis. Arch Intern Med. 2006 Sep 25;166(17):1899-906.

Scharf HP, Mansmann U, Streitberger K, Witte S, Kramer J, Maier C, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006 Jul 4;145(1):12-20.

Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN. Acupuncture in patients with osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm. Arthritis Rheum. 2006 Nov;54(11):3485-93.

Review Date:
3/19/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Gear Review: New Balance 1063 Running Shoes

FitSugar — Mon, 23 Feb 2009 12:00:00 -0800

Whether you're a fan of New Balance sneakers or not, I think you're going to want to know about the latest update to their 1063 running shoe. The New Balance 1063 ($125) is considered a high mileage, technical running shoe. Although lightweight (9.5 oz. per shoe), this shoe offers the great cushioning and remains flexible. It's a neutral running shoe, designed for runners who have "normal arches."

Want to hear what my favorite thing about these sneakers is? Then read more.

Check out those laces. They're called SureLaces, and the wavy design ensures that your laces won't loosen while you run, so they offer added support to keep your sneaker snug around your foot. I also love the mesh material that covers the entire sneaker, offering breathability. Even on my longer runs, my feet never overheated, and the shock absorption protected my feet and knees. The shoe comes in orange or blue, and I know this 1063 is on the pricier side, but that's because it's top of its class when it comes to neutral sneakers. If you're serious about running, a more expensive sneaker really does feel different especially on those longer runs.

You can buy them directly from the New Balance website.

Osteoporosis

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

In This Report

Highlights
Introduction
Causes
Symptoms
Fractures
Risk Factors
Diagnosis
Lifestyle Changes
Medications
Treatment
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approvals

In 2007, the Food and Drug Administration (FDA) approved zoledronic acid (Reclast) for postmenopausal osteoporosis treatment. Zoledronic acid is given as an injection once a year. A 2007 study in the New England Journal of Medicine indicated that zoledronic acid can significantly reduce the risk of spine, hip, and other fractures.
In 2007, the FDA approved raloxifene (Evista) for prevention of breast cancer in postmenopausal women with osteoporosis and postmenopausal women at high risk for breast cancer. Raloxifene was previously approved for prevention and treatment of osteoporosis.

Calcium and Vitamin D for Osteoporosis Prevention

In 2007, the Food and Drug Administration proposed allowing manufacturers of food and supplements to put a health claim on their products stating that the combination of calcium and vitamin D can reduce the risk of osteoporosis.
In 2007, the National Osteoporosis Foundation updated its daily intake guidelines to recommend 1,200 mg of calcium, and 800 - 1,000 IU of vitamin D3, for adults age 50 and older.
Calcium plus vitamin D is effective in preventing osteoporosis in people age 50 years and older, according to a 2007 review in the Lancet. The researchers found that a minimum of 1,200 mg of calcium and at least 800 IU of vitamin D per day gave the most protection.

Fosamax: Taking a Break (Without Breaking a Bone)

Women at low risk for fracture may be able to temporarily stop taking alendronate (Fosamax) after 5 years, suggests a 2006 study in the Journal of the American Medical Association.

Antidepressants and Osteoporosis Risk

Selective serotonin reuptake inhibitors (SSRIs), the most commonly used class of antidepressants, may increase the risk for bone loss in both older men and women, according to several studies published in 2007 in the Archives of Internal Medicine. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). The researchers did not find that other types of antidepressants are associated with reduced bone mineral density.

Introduction

Osteoporosis is a disease of the skeleton in which bones become brittle and prone to fracture. In other words, the bone loses density. Osteoporosis is diagnosed when bone density has decreased to the point where fractures occur with mild stress.

The skeleton consists of groups of bones which protect and move the body.

Until a healthy person is around age 40, the process of breaking down and building up bone by cells called osteoclasts and osteoblasts is a nearly perfectly coupled system, with one phase stimulating the other. As a person ages, or in the presence of certain conditions, this system breaks down and the two processes become out of sync. The reasons why this occurs during aging are not clear. Some individuals have a very high turnover rate of bone, some have a very gradual turnover, but the breakdown of bone eventually overtakes the build-up.

The Function of Bones. The skeleton has a dual function:

It provides structural support for muscles and organs.
It also serves as a depot for the body’s calcium and other essential minerals, such as phosphorus and magnesium.

The skeleton holds 99% of the body’s calcium. The remaining 1% circulates in the blood and is essential for crucial bodily functions, ranging from muscle contraction to nerve function to blood clotting.

Bone Turnover: the Breakdown and Growth of Bones. Like other organs in the body, bone tissue is constantly being broken down and reformed again. This turnover is necessary for growth, for repair of minor damage that occurs from everyday stress, and for the maintenance of a properly functioning body. Two essential cells are involved in this process:

Osteoblast cells are produced by bone cells and are the bone builders. They rebuild the skeleton, first by filling in the holes with collagen, and then by laying down crystals of calcium and phosphorus.
Osteoclast cells are formed from certain blood cells and are responsible for the breakdown, or resorption, of the skeleton. These cells dig holes into the bone and release the small amounts of calcium into the bloodstream that are necessary for other vital functions.

Each year, about 10 - 30% of the adult skeleton is remodeled in this way. The bone build up (formation)-break down (resorption) balance is controlled by a complex mix of hormones and chemical factors. If bone resorption occurs at a greater rate than bone build up, your bone loses density and puts you at risk for osteoporosis.

In women, estrogen loss after menopause is associated with rapid resorption and loss of bone density. This group, then, is at highest risk for osteoporosis and therefore for fracture.

There are two primary kinds of osteoporosis: type I and type II:

Type I. Type I, or high turnover, osteoporosis occurs in 5 - 20% of women, most often between the ages of 50 and 75. This is because of the sudden postmenopausal decrease in estrogen levels, which results in a rapid depletion of calcium from the skeleton. This is associated with fractures that occur when the vertebrae compress together, causing a collapse of the spine. It is also associated with fractures of the hip, wrist, or forearm caused by falls or minor accidents. Women have a higher risk for type 1 osteoporosis than men.
Type II. Type II, or low turnover, osteoporosis (also known as age-related or senile osteoporosis) results when the process of resorption and formation of bone are no longer coordinated, and bone breakdown overcomes bone building. (This occurs with age in everyone to some degree.) Type II osteoporosis affects both men and women and is primarily associated with leg and spinal fractures. Older women can have both type I and type II osteoporosis.

Click the icon to see an image of a compression fracture.

What determines the existence of osteoporosis, whether type I or type II, is the amount of calcium left in the skeleton and whether it places a person at risk for fracture. Someone who has exceptionally dense bones to begin with will probably never lose enough calcium to reach the point where osteoporosis occurs, whereas a person who has low bone density could easily develop osteoporosis despite losing only a relatively small amount of calcium.

Secondary osteoporosis is caused by other conditions, such as hormonal imbalances, diseases, or medications (such as corticosteroids or anti-seizure drugs).

Click the icon to see an image of osteoporosis.

Causes

Because the patterns of reforming and resorbing bone often vary from patient to patient, experts believe several different factors account for this problem. Important chemicals (such as estrogen, parathyroid hormone, and vitamin D) and blood factors that affect cell growth are involved with this process. Changes in levels of any of these factors could play a role in the development of osteoporosis.

Although ordinarily associated with women, sex hormones play a role in osteoporosis in both genders, most likely by controlling the birth and duration of life of both osteoclasts (bone breakers) and osteoblasts (bone builders).

Women and Estrogen. Experts are still puzzled by the rapid decline in bone density after menopause, when a woman’s ovaries stop producing estrogen. Estrogen comes in several forms:

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

The most potent form of estrogen is estradiol. Estradiol deficiency appears to be a very strong factor in the development of osteoporosis.
The other important but less powerful estrogens are estrone and estriol.

The ovaries produce most of the estrogen in the body, but it can also be formed in other tissues, such as body fat, skin, and muscle. After menopause, some amounts of estrogen continue to be manufactured in the peripheral body fat. Even though the ovaries have stopped producing estrogens directly, they continue to be a source of the male hormone testosterone, which converts into estradiol.

Estrogen may have an impact on bone density in various ways:

Estrogen’s most important effect on osteoporosis appears to be prevention of bone breakdown (resorption). Some research suggests that estrogen may control the life span of osteoclasts, the cells responsible for bone breakdown.
One study reported that part of estrogen’s beneficial actions may involve maintaining normal levels of vitamin D, an important nutrient in bone protection.

Men and Androgens and Estrogen. In men, the most important androgen (male hormone) is testosterone, which is produced in the testes. Other androgens are produced in the adrenal glands. Androgens are converted to estrogen in various parts of a man’s body, including bone.

Click the icon to see an image of the adrenal glands.

Studies have suggested that the loss of estrogen as well as testosterone may contribute to bone loss in elderly men. In one study, elderly men were first given a drug that blocked their normal hormones and then were given estrogen and testosterone patches. When the estrogen patch was removed, the bone breakdown process accelerated. When both patches were removed, the number of the bone-building cells (the osteoblasts) decreased. In other words, both hormones appeared to be integral to bone function in men.

Low levels of vitamin D and high levels of parathyroid hormone (PTH) are associated with hip fracture in women after menopause:

Vitamin D is a vitamin with hormone-like properties. It is essential for the absorption of calcium into the bone and for normal bone growth. Lower levels result in impaired calcium absorption, which in turn causes an increase in PTH.
Parathyroid hormone (PTH) is produced by the parathyroid glands. These are four small glands located on the surface of the thyroid gland. They are the most important regulators of calcium levels in the blood. When calcium levels are low, the glands secrete more PTH, which then increases blood calcium levels. High persistent levels of PTH stimulate bone resorption (bone loss).

Click the icon to see an image of the benefits of vitamin D.

Click the icon to see an image of the sources of vitamin D.

Click the icon to see an image of the parathyroid glands.

Several studies on family members, including twins, have strongly suggested that genetic factors help determine bone density. Some examples include the following:

Of particular interest are genetic factors that affect vitamin D, a critical nutrient for calcium absorption in the body.
Many studies are looking at abnormalities in genes that may cause deficiencies in estrogen receptors, molecules that help estrogen work on cells. Estrogen is important in maintaining bone density in both men and women.

Corticosteroids. More than 30 million Americans have disorders that are commonly treated using corticosteroid drugs (also called glucocorticoids or steroids). Oral corticosteroids can reduce bone mass in both men and women. It is not clear whether inhaled steroids carry the same risks, but some studies indicate that they may cause bone loss when taken at higher doses for long periods of time. (Children on inhaled steroids may have temporary impaired growth, but they do not appear to be at risk for bone loss.)

Antidepressants. Selective serotonin reuptake inhibitors (SSRIs) -- a class of antidepressants that includes fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) -- may be associated with bone loss in both older men and women, according to two 2007 studies in the Archives of Internal Medicine. The researchers did not find an increased risk for bone loss with other types of antidepressants.

Diuretics. Diuretics, which are used to treat high blood pressure, have different effects on osteoporosis, depending on the type. Loop diuretics, such as furosemide (Lasix), increase the kidneys’ excretion of calcium, which can lead to thinning bones. Thiazide diuretics, on the other hand, protect against bone loss, but this protective effect ends after use is discontinued.

Contraceptives. Hormonal contraceptives that use progestin without estrogen (such as Depo-Provera injection or other progestin-based contraceptives), can cause loss of bone density. For this reason, the Food and Drug Administration (FDA) recommends that Depo-Provera injections should not be used for longer than 2 years. Some, but not all, studies suggest that combination estrogen-progestin oral contraceptives increase the risk for osteoporosis later in life. Women who take birth control pills should be sure to get adequate calcium and vitamin D from diet or supplements.

Other Medications. Anti-epileptic (anti-seizure) drugs increase the risk for bone loss (as does epilepsy itself). Other drugs that increase the risk for bone loss include the blood-thinning drug heparin, and hormonal drugs that suppress estrogen (such as gonadotropin-releasing hormone agonists). A 2006 study in the Journal of the American Medical Association suggested that long-term (greater than 1 year) use of proton-pump inhibitors (PPIs) may increase the risk for hip fractures. PPIs are used to treat gastroesophageal reflux disease (heartburn) and include omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium).

Predisposing Medical Conditions. Osteoporosis can be secondary to several other conditions, including alcoholism, diabetes, hyperthyroidism, epilepsy, chronic liver or kidney disease, celiac disease, scurvy, rheumatoid arthritis, leukemia, cirrhosis, gastrointestinal diseases, vitamin D deficiency, hypogonadism (impaired development of reproductive organs), lymphoma, hyperparathyroidism, and rare genetic disorders such as Marfan and Ehlers-Danlos syndrome.

Symptoms

Many people confuse osteoporosis with arthritis and believe they can wait for symptoms such as swelling and joint pain to occur before seeing a doctor. However, the mechanisms that cause arthritis are entirely different from those in osteoporosis. Osteoporosis usually becomes quite advanced before symptoms appear.

All too often, osteoporosis becomes apparent in dramatic fashion: a fracture of a vertebra (backbone), hip, forearm, or any bony site if sufficient bone mass is lost. These fractures frequently occur after apparently minor trauma, such as bending over, lifting, jumping, or falling from the standing position.

Pain, disfigurement, and debilitation are common in the latter stages of the disease. Early spinal compression fractures may go undetected for a long time, but after a large percentage of calcium has been lost, the vertebrae in the spine start to collapse, gradually causing a stooped posture called kyphosis, or a "dowager’s hump." Although this is usually painless, patients may lose as much as 6 inches in height.

Click the icon to see an image of osteoporosis.

Fractures

Bone density loss from osteoporosis is a major cause of disability and death in the elderly, mostly due to subsequent fractures. The lifetime risk of spinal fracture in women is about one in three, and that for hip fracture is one in six. Women at highest risk for fractures are those with low bone density plus a history of fractures, particularly nonviolent fractures.

Click the icon to see an animation about osteoporosis.

Each year, there are an estimated 500,000 spinal fractures, 300,000 hip fractures, 200,000 broken wrists and 300,000 fractures of other bones. About 80% of these fractures occur after relatively minor falls or accidents.

Between 25 - 60% of women older than age 60 develop spinal compression fractures. Studies on men with osteoporosis report that they have a 6% risk for hip fracture and between 16 - 25% risk for any fractures related to osteoporosis.

Click the icon to see an image of a compression fracture.

Click the icon to see an image of a hip fracture.

Unfortunately, studies continue to report inadequate treatment after a fracture. In a major 2003 study, for example, only 8.4% of women who had sustained fractures were tested for osteoporosis. Worse, less than half of these women received any treatment for osteoporosis. Overall, in the study fewer than 4% of men and half of women who had sustained fractures were evaluated and treated according to recommended guidelines. The older a woman was, the less likely she was to have adequate treatment.

Risk Factors for Fracture and Falling. The risk for fracture itself in people with low bone density is compounded by certain features. Having multiple risk factors for osteoporosis itself poses a higher risk for fractures. However, not all older women with osteoporosis develop fractures. There is some evidence that the body partially compensates after menopause by increasing bone strength, which can help offset the risk for fracture.

Falling, of course, is the primary risk factor for fracture. So, additional risk factors for fracture are those that increase the risk for falling. They include:

Having chronic medical problems (emphysema, heart disease, stroke, arthritis, and depression), with the risk increasing with multiple health problems. Such problems may account for 30% of falls in older women.
Taking multiple medications (especially tranquilizers and antidepressants).
Poor physical function, importantly slow gait and reduced muscle strength. Inactivity that results in weak thigh muscles and poor balance particularly puts any older person at risk for fracture and particularly those with low bone density.
Poor concentration or mental impairment.
Impaired vision.
Hazardous environment (such as the presence of throw rugs in the house).

Between 25 - 36% of women who experience a hip fracture die within a year afterward, and about a quarter of the patients require nursing home treatment. The mortality rates after major fractures may be even higher in older men than in older women. Mortality rates after hip fractures declined from the 1960s through the early 1980s, but they have since leveled off. Whether or not medical advances can improve mortality rates in the future, prevention of osteoporosis is extremely important.

Risk Factors

Gender. An estimated 10 million adults in the United States have osteoporosis and another 34 million have low bone mass that places them at risk for developing osteoporosis. A 2004 report from the Surgeon General's office estimates that by 2020, half of all Americans over age 50 could be at risk for this condition. Eighty percent of people with osteoporosis are women. Men start with higher bone density and lose calcium at a slower rate than women, which is why their risk is far lower. Nevertheless, after age 50, bone loss increases and, according to recent studies, more rapidly than previously thought.

Ethnicity. Although adults from all ethnic groups are susceptible to developing osteoporosis, Caucasian and Asian women and men face a comparatively greater risk. About 20% of non-Hispanic white and Asian women older than age 50 have osteoporosis, and over 50% are at risk due to low bone mass. Osteoporosis affects 10% of Hispanic women (49% at risk) and 5% of non-Hispanic black women (35% at risk). Body type can also be a factor. Osteoporosis is more common in women who have a small, thin body frame and bone structure.

Events associated with estrogen deficiencies are the primary risk factors for osteoporosis in women.

Natural and Surgical Causes of Estrogen Deficiency.

Menopause. Within 5 years after menopause, the risk for fracture increases dramatically. Fractures occurring during this period are more likely to occur in the wrist or spine than the hip, but their occurrence is a strong predictor of later severe osteoporosis and hip fracture.
Surgical removal of ovaries.
Missing periods for 3 months or longer.
Never giving birth.
Pregnancy and nursing do not increase the risk for osteoporosis even though during those times calcium is diverted from the mother to the baby. A factor believed to be associated with reduced bone density is elevated at a constant level during nursing, but as the baby is weaned, levels of the factor decline and bone formation is restored.

Female Athlete Triad. In athletes, excessive exercise plays a major role in many cases of anorexia (and, to a lesser degree, bulimia), which in turn increases the risk for low estrogen levels and bone loss. The term "female athlete triad" in fact, is now a common and serious disorder facing young female athletes and dancers and describes the combined presence of the following problems:

Osteoporosis
Amenorrhea (absence or irregular menstruation)
Eating disorders

Some specific risk factors in men include:

Hormonal deficiencies, including both testosterone and estrogen, which occur in older men (although much more slowly than in women). Estrogen deficiencies may also play a major role in osteoporosis in older men. It is unknown yet what normal estrogen levels are in men.
Medical conditions that can reduce testosterone levels, such as prostate cancer treatments, testicular surgery, and mumps.
Hypogonadism, which is a severe deficiency in the primary hormone that signals the process leading to the release of testosterone and other important reproductive hormones.

Of concern, are studies suggesting that men who have osteoporosis and suffer hip fractures are far less likely to be tested and treated for low bone density than are women. In one study, only 27% of men were treated for osteoporosis compared to 71% of women.

Dietary Factors. Diet plays an important role in preventing and speeding up bone loss in men and women. Calcium and vitamin D deficiencies, of course, are important factors in the risk for osteoporosis. Other dietary factors may also be harmful or protective for certain people.

Calcium requires adequate vitamin D in order to be absorbed by the body. In the United States, many food sources of calcium such as milk are fortified with vitamin D.

Click the icon to see an image of the sources of calcium.

Lack of Exercise. Lack of exercise can put thinner people at risk for osteoporosis.

Being Underweight. Being underweight is a risk factor for osteoporosis in men as well as women. (Shortness, thinness, and narrow hips all increase the risk for fracture in people with low bone density.)

Lack of Sunlight. The photochemical effect of sunlight on the skin is a primary source for vitamin D. Bone formation peaks in the summer and bone breakdown increases in the winter. People who avoid sun exposure to prevent skin cancer may be at risk for vitamin D deficiency, particularly it they are elderly.

Click the icon to see an image of the sources of vitamin D.

Smoking. Women who smoke, particularly after menopause, have a significantly greater chance of spine and hip fractures than those who don’t smoke. Men who smoke also have lower bone density.

Diabetes. Diabetes changes bone quality and density and increases the risk for osteoporosis, but the effects differ depending on type:

Type 1 diabetes is associated with a slightly reduced bone density, putting patients at risk for osteoporosis and possibly fracture.
Type 2 diabetes, on the other hand, is associated with an increased bone density. In such cases, the bone quality itself may be impaired, since people with type 2 diabetes are still at higher risk for fractures.

Older patients with any diabetes type are at high risk for falling, which compounds the risk for fracture.

The maximum density that bones achieved during the growing years is a major factor in whether a person goes on to develop osteoporosis. Persons, usually women, who never develop peak bone mass in early life are at high risk for osteoporosis later on. Children at risk for low peak bone mass include children who are:

Born prematurely
Have anorexia nervosa (more common in girls)
Young, highly competitive athletes
Take oral corticosteroid drugs (inhaled steroids, which are common in asthma treatments, appear to pose a very low risk or none at all)
Have certain medical conditions (cystic fibrosis, epilepsy, inflammatory bowel disease, and celiac disease)
Have delayed puberty

Although to a large extent genetics predict bone health, exercise and good nutrition during the first three decades of life (when peak bone mass is reached) are still excellent safeguards against osteoporosis (and countless other health problems).

Diagnosis

About 20 - 30% of Caucasian women in the U.S. can expect to be affected by osteoporosis, including having a spinal fracture, after age 60. Hispanic, Asian, and Native American women have an even higher risk. Nearly all of them are unaware of the condition and so fail to seek a diagnosis. Even worse, studies continue to report inadequate evaluation for osteoporosis even after a fracture.

Evidence suggests that screening for osteoporosis can help prevent fractures. Expert groups now recommend bone density screening for the following people:

All women over age 65.
Any postmenopausal women under 65 years with risk factors for osteoporosis (being thin, being a smoker, having a family history of osteoporosis, corticosteroids use, or any serious high-risk condition, such as hyperthyroidism or early menopause).
Any older men or women who suffer a fracture. (Unfortunately, studies suggest that only a minority of these patients are evaluated and treated for osteoporosis. Men are especially less likely to be tested.)

Whether perimenopausal women should be screened is unclear. (Perimenopause is the period that extends a few years before and after menopause, usually ages 50 - 59.) Some experts believe that women as young as 21 who have strong risk factors for osteoporosis (such as anorexia or absence of menstruation due to over-exercising) should consider being tested. It is also important that older women continue to get bone density tests. A 2006 study found that only 10% of women over age 75 receive bone density screenings, even though they are the age group most likely to have hip fractures.

Bone Densitometry. The standard technique for determining bone density is a form of bone densitometry called dual-energy x-ray absorptiometry (DEXA). DEXA is simple and painless and takes 2 - 4 minutes. The machine measures bone density by detecting the extent to which bones absorb photons that are generated by very low-level x-rays. (Photons are atomic particles with no charge.) Measurements of bone mineral density are generally given as the average concentrations of calcium in areas that are scanned.

A bone density scan measures the density of bone in a person. The lower the density of a bone the higher the risk of fractures. A bone scan, along with a patient's medical history, is a useful aid in evaluating the probability of a fracture and whether any preventative treatment is needed. A bone density scan has the advantage of being painless and exposing the patient to only a small amount of radiation.

Bone mineral density is usually measured at the hip rather than the spine or wrist, which appears to be the most predictive of hip fracture. (Hip fractures are the most dangerous fractures, particularly in women older than sixty.) The bone density in the spine may also be measured. (Spinal bone density in older people however may be misleading. Bone density in this group may increase because of compression on the spinal bones from arthritic changes in the spine. Therefore, bone density measurements may be normal or even high, but the patient may actually be at risk for fracture.)

Click the icon to see an image of a hip fracture.

Ultrasound. Ultrasound techniques measure bone density in the heels, fingers, and leg bones. In early studies, advanced ultrasound techniques, such as quantitative ultrasound (QUS), are promising for improving accuracy in predicting fractures when used with DEXA. Ultrasound itself is less expensive than DEXA and uses no radiation. Ultrasound bone tests are sometimes given at health fairs or other non-medical settings. It should be noted that these results typically vary widely from measurements of the hipbone and are not reliable when used alone.

Quantitative Computed Tomography. Quantitative computed tomography (QCT) scans, a form of CT scans, can provide highly detailed information about spinal density. Radiation doses from this technique are higher than the others. Whether QCT predicts fracture risk accurately is, however, unknown.

Osteoporosis is diagnosed when bone density has decreased to the point where fractures will happen with mild stress, the so-called fracture threshold. This is determined by measuring bone density and comparing the results with the norm. However, low scores on bone density are not very accurate in determining fracture risk without consideration of other risk factors for fracture.

In general, doctors take the following steps to determine osteoporosis:

Bone mineral density ) is measured, typically in the hipbone, using bone densitometry.
Measurements of bone mineral density are given as mg/cm.² This is the average concentration of bone mineral in the areas that are being scanned. In general, bone is normal if results are greater than 833 mg/cm.² Low bone density (osteopenia) is between 833 and 648 mg/cm.² Osteoporosis is diagnosed with results below 648 mg/cm.²

These measurements still do not always indicate the true risk for fracture. The doctor also assesses risk factors and other considerations. The next step is to compare the patient's bone mineral density to normal bone density, which is defined as the average bone mineral density in the hipbones of premenopausal Caucasian women. (This group is used as the basis for the norm because of their high risk and greater proportion in the American population.)

The health professional then uses this comparison to determine her standard deviation (SD) from this norm. Standard deviation results are given as Z and T scores:

A T score gives the standard deviation of the patient in relationship to the norm in young adults. Doctors often use the T-score and other risk factors to determine the risk for fracture.
A Z score gives the standard deviation of the patient in relationship to the norm in her own age group. Z scores may be used to monitor the effects of treatments in women who have been diagnosed with osteoporosis.

For example, the lifetime risks for a younger woman with a specific T-score would be higher than the same scores in an older woman because the younger woman would have a longer time to lose bone density. In general, the T scores in a 55-year-old woman suggest the following degrees of risk for hip fracture.

One standard deviation or less below the norm indicates normal bone mineral density. (This carries a lifetime chance for a hip fracture of up to about 20%, depending on age and other risk factors.)
Between 1 and 2.5 standard deviation s below normal defines osteopenia, which is low bone density. This carries between a 20 - 50% lifetime risk for fracture.
More than 2.5 standard deviation s predicts osteoporosis and over a 60% chance for hip fracture. Additional risk factors increase the risk. They include low weight, smoking, risks for falling, and especially a history of previous fractures. For example, in women 65 years old with low bone density but no adverse factors, the risk for fracture is 4.3% in 1 year and 28.6% over 5 years. In similar women with a previous fracture, the probability of fracture at 1 year is 11% and at 5 years is 71.8%.

Not all older women with osteoporosis develop fractures. There is some evidence that the body partially compensates after menopause by increasing bone strength, which can help offset the risk for fracture. Techniques to measure bone strength may better identify women at higher or lower risk.

Note: Because the standards are based on Caucasian women, they do not necessarily apply to men, children, or to non-Caucasian women. For example, men have a lower risk for fracture at the same standard deviations as women. Researchers are attempting to establish risk guidelines for these groups as well.

Laboratory blood or urine tests for identifying certain markers of bone loss may prove to be useful in certain cases:

High levels of the chemicals deoxypyridinoline and C-telopeptide in the blood may indicate increased risk for hip fracture. These substances are produced when bone is broken down.
A urine test detecting a substance called N-telopeptide may indicate bone loss (although it is not associated with any risk for fracture).

Lifestyle Changes

Because osteoporosis affects such a considerable portion of the female population, total prevention may not be possible, particularly for high-risk groups. Once a woman goes through menopause and more rapid bone depletion occurs, the line between prevention and treatment blurs. Despite their lower risk for osteoporosis, men should also protect their bones with the same healthy lifestyle habits.

Exercise is very important for slowing the progression of osteoporosis. Although mild exercise does not protect bones, moderate exercise (more than 3 days a week for more than a total of 90 minutes a week) reduces the risk for osteoporosis and fracture in both older men and women. Everyone who is in good health should aim for more. Exercise should be regular and life-long. Before beginning any strenuous exercise program, older patients, those at risk or those who have serious medical conditions, should talk to their doctors.

Specific exercises may be better than others, depending on the age group:

Children should begin exercising before adolescence, since bone mass increases during puberty and reaches its peak between ages 20 and 30. Some evidence suggests that exercise may help develop bone mass in teenagers more effectively than high calcium intake. High-intensity exercises may be particularly bone-strengthening in young people. (Such regimes should not be confused with the athlete-triad -- intense competitive exercise, eating disorders, and menstrual irregularities -- that causes osteoporosis in young athletes.)
Weight-bearing exercise applies tension to muscle and bone and, in young people, encourages the body to compensate for the added stress, increasing bone density by as much as 2 - 8% a year. In premenopausal women these exercises are very protective. (Young men need high-intensity exercises to increase bone mass.) Careful weight training is also very beneficial for elderly people, especially women.
Regular brisk long walks improve bone density and mobility and may relieve osteoarthritic pain. High-impact exercises can be very bone-protective in young and middle-aged adults who have no precluding medical or physical conditions. Most older individuals should avoid high-impact aerobic exercises (step aerobics), which increase the risk for osteoporotic fractures. (Older people, particularly women who engage in jumping exercises should do so under supervision.) Although low-impact aerobic exercises such as swimming and bicycling do not increase bone density, they are excellent for cardiovascular fitness and should be part of a regular regimen.
Exercises specifically targeted to strengthen the back help prevent fractures later on in life and can be beneficial in improving posture and reducing kyphosis (hunchback), even in people with existing severe conditions.
Low-impact exercises that improve concentration, balance, and strength, particularly yoga and tai chi, have been found to decrease the risk of falling. In one study, tai chi reduced the risk of falling by almost half.

Exercise plays an important role in the retention of bone density in the aging person. Studies show that exercises requiring muscles to pull on bones cause the bones to retain and possibly gain density.

Click the icon to see an image of osteoporosis.

In 2007, the Food and Drug Administration (FDA) proposed a new health claim for foods and dietary supplements that contain calcium and vitamin D. The FDA’s recommendation will allow manufacturers of these products to state that the combination of calcium and vitamin D can reduce the risk of osteoporosis. Also in 2007, the National Osteoporosis Foundation (NOF) updated its recommendations for getting enough calcium and vitamin D3. The NOF now recommends 1,200 mg of calcium/day and 800 - 1,200 I.U. of vitamin D3/day for adults age 50 and older. (For strong bones, people need enough of both calcium and vitamin D.)

For years, doctors have recommended that women take supplements of calcium plus vitamin D to help maintain bone density and reduce the risk for fractures. Many studies, including a 2007 review in the Lancet, show that a combination of calcium and vitamin D can help prevent osteoporosis. However, a 2006 New England Journal of Medicine study raised some questions about this approach. In the Women’s Health Initiative study, women were randomly assigned to receive either 1,000 mg of calcium carbonate plus 400 IU of vitamin D a day or placebo. The results indicated that daily calcium and vitamin D supplements:

Improve slightly (by 1%) hip bone density
Prevent hip fracture, but only for women who consistently take the supplements. (Another 2006 study supported this finding.)
Do not prevent spine or other types of fractures
Produce a slight increase in the risk of kidney stones

The medical community has differing views on how to interpret these findings. Some doctors recommend that women over age 60 should still consider taking calcium and vitamin D for bone health. Other doctors feel that due to the risks of kidney stones, supplements are beneficial only for women (especially those over age 70) who do not get enough calcium in their diets. Ask your doctor whether or not you should take calcium supplements.

Appropriate Daily Doses. Recommended daily amounts of calcium depend on age and risk factors:

In young people, children ages 3 - 8 should take 800 mg of calcium per day, while children and adolescents ages 9 - 17 need 1,300 mg per day. Teenage girls who do not have enough calcium in their diets should consider taking supplements, which can help build bone density during these critical years.
The standard recommended dose for people over age 50 is about 1,200 mg per day, but actual dosage may be higher or lower depending on risk factors. Even doses of 1,000 mg may help preserve bone in many postmenopausal women without osteoporosis, including during winter months (when bone loss is greatest). In women who have already experienced osteoporosis-related fractures, however, 1,000 mg daily may not add any protective benefits without bone-building medication.
Some experts suggest that all pregnant women, adolescents, and those on corticosteroids take 1,000 - 1,300 mg of calcium every day.
Breast-feeding women should have 2,000 mg per day.

Forms of Calcium Supplements. There are several different kinds of calcium supplements, such as calcium carbonate (Caltrate, Os-Cal, Tums), calcium citrate (Citracal), calcium gluconate, and calcium lactate. Although each kind provides calcium, they all have different calcium concentrations, absorption capabilities, and other actions. Their value in preserving bones depends on many different factors:

Calcium Concentrations. Forty percent of calcium carbonate is actually calcium, whereas calcium citrate is 24% calcium, and calcium gluconate is only 9% calcium.
Calcium Absorption Capabilities. The calcium must also be absorbed from the stomach into the bloodstream. Calcium citrate is better absorbed than many other calcium compounds. It was reported to be the first calcium supplement to preserve bone density after menopause. (Calcium citrate also increases iron absorption. Milk and other calcium compounds tend to reduce iron absorption.) One simple method for testing the absorbency of a particular brand of calcium tablet is to place it in a glass of white vinegar at full strength and check to be sure that it breaks up within 30 minutes. Taking large amounts of antacids can impair calcium absorption. People should take calcium supplements after meals.

Side Effects. Calcium supplements, even at normal doses of about 1,000 mg a day, can increase the risk for kidney stones. People should be careful not to exceed the upper limit of 2,500 mg per day. (Because many commercial foods are now fortified with calcium, this upper limit may be easier to reach than people think.) Calcium may boost the effects of drugs used to treat osteoporosis.

Click the icon to see an image of kidney stones.

Although not a specific side effect of calcium, there has been much public concern about reports of a small amount of lead in calcium supplements. Although exposure to high levels of lead can cause health problems, the amount in such supplements is very small and may pose little or no hazard.

Vitamin D. Vitamin D helps the stomach and the gastrointestinal tract absorb calcium. It also is the essential companion to calcium in maintaining strong bones. Moreover, vitamin D protects against osteoporosis only in combination with calcium.

Click the icon to see an image of the benefits of vitamin D.

Vitamin D is made in the skin using energy from the ultraviolet rays in sunlight. People also can get it from dietary supplements.

As a person ages, vitamin D levels decline. They also fall during winter months and when people have inadequate sunlight. Pollution may also contribute to less sunlight and declining vitamin D levels.

Click the icon to see an image of the sources of vitamin D.

Most current adult guidelines recommend:

400 IU (10 mcg) for people aged 50 - 60.
600 IU (15 mcg) for those over age 70 who do not have sufficient exposure to sunlight. (Evidence suggests that higher doses of vitamin D -- up to 1,000 IU per day -- may help prevent fractures in people with osteoporosis.)

There are various recommendations for daily vitamin D intake. In 2007, the National Osteoporosis Foundation updated its guidelines to recommend 400 - 800 IU of vitamin D3 for adults younger than age 50, and 800 - 1,000 IU of vitamin D3 for adults age 50 and older. Vitamin D3, also called cholecalciferol, is the form of vitamin D that is best for bone health. In addition to supplements, food sources for vitamin D3 include fortified milk, egg yolks, saltwater fish, and liver.

In 2007, the U.S. National Institute of Health’s Office of Dietary Supplements released a report regarding vitamin D and bone health. Researchers were not able to definitely separate the effect of vitamin D from that of calcium, as most clinical trials evaluate the combination of these supplements. The report did indicate that a combination of daily vitamin D3 (700 - 800 IU) and calcium (500 - 1,200 mg) decreases the risks of falls, fractures, and bone loss in elderly people (ages 62 - 85 years).

Sufficient sunlight exposure and drinking milk fortified with vitamin D supply most people’s normal needs for vitamin D. One cup of whole milk provides about 100 IU of vitamin D.

Vitamin D is toxic in doses above 2,000 IU a day. No one should exceed the recommended daily intake of vitamin D except under the direction of a doctor.

Many people could become deficient in vitamin D as they avoid sunlight to prevent skin cancers and instead increase their intake of milk products, such as yogurt and skim milk, which may have little vitamin D. Such individuals may need to take supplements. People with darker skin have a higher risk for vitamin D deficiency than those with lighter skin.

Vitamin D derivatives are being investigated for treating osteoporosis. Calcitriol (Calcijex, Rocaltrol), for example, is a prescription-form of vitamin D that can increase bone mass and decrease the rate of spinal fractures. However, calcitriol increases the risk for high blood calcium levels (hypercalcemia) and requires frequent monitoring.

Vitamin K. Vitamin K has properties that protect bone and prevent fracture. Because intestinal bacteria produce vitamin K, and the vitamin is found in leafy vegetables, deficiencies are rare. Some evidence suggests, however, that people may not be consuming enough of this nutrient. Vitamin K affects blood clotting, and taking supplements is not recommended without first talking to a doctor. Vitamin K2 (menatetrenone), a form of vitamin K, may help prevent fractures in people with osteoporosis.

Click the icon to see an image of the benefits of vitamin K.

Click the icon to see an image of the sources of vitamin K.

Vitamin B12. Studies suggest that people need the right amounts of vitamin B12 and folic acid to maintain their bone mineral density.

Vitamin A. High amounts of dietary vitamin A reduce bone density and may even increase the risk for fracture in postmenopausal women. (A form of vitamin A, retinoic acid, has been found to stimulate bone breakdown.)

The DASH Diet and Low Sodium. Perhaps a good general approach for people at risk for osteoporosis (or almost any adult) is the DASH diet plus sodium (salt) restriction. The DASH (Dietary Approaches to Stop Hypertension) diet is used to help people with hypertension maintain healthy blood pressures. A 2003 study also reported that it might help protect bones and improve cholesterol levels. This diet not only is rich in important nutrients and fiber but also includes foods that contain far more potassium, calcium, and magnesium, than are found in the average American diet. All of these minerals are important for bone protection. The dietary recommendations are as follows:

Avoid saturated fat (although include calcium-rich dairy products that are no- or low-fat). When choosing fats, select monounsaturated oils, such as olive or canola oils. These fats are also found in some fish. Although no one wants to be overweight, even a slight excess of fat helps protect bones. In one study, women who ate more fat in their diet were, on average, better able to absorb calcium than were women who had been put on a low-fat, high-fiber diet.
Choose whole grains over white flour or pasta products. Include nuts, seeds, or legumes (dried beans or peas) daily.
Choose fresh fruits and vegetables every day. Many of these foods are rich in potassium, magnesium, and other minerals that are important for bone (as well as heart) protection.
Choose protein preferably from fish, poultry, or soy products. Soy in combination with fiber-rich foods or supplements may have specific benefits. Oily fish may also be particularly beneficial. They contain omega-3 fatty acids, which have been associated with heart and nerve protection.

Salt Restriction. Reducing salt may protect both the heart and the bones. High sodium intake interferes with calcium retention. Note: Fast foods and commercial snacks are usually high in sodium and have been linked with weak bones.

Dairy Products and Calcium-Rich Foods. Although some studies have reported that dairy products benefit the bones, it is not entirely clear if high-calcium diets reduce the risk for fractures compared to adequate intake of vitamin D. Until more is known, people should be sure their diets have sufficient calcium. Dietary calcium is available from many good sources.

Milk and Dairy Products. The best source of calcium in the diet is from milk fortified with vitamin D. Four glasses of milk provide about 1,200 mg of calcium. (Skim milk and yogurt products, unfortunately, are often low in vitamin D, which is important for calcium absorption.) According to a 2003 study, girls who have low milk intake increase their risk for fracture in adulthood. One report even suggests that milk proteins actually slow bone break down. It is not clear, however, if drinking milk after menopause offers any significant bone protection.
Other Calcium-Rich Foods. Other calcium-rich foods include shrimp, canned salmon or sardines, black strap molasses, calcium-fortified tofu, and almonds. A number of commercial foods, including orange juice and some cereals, are now calcium fortified. Dark green vegetables (broccoli, kale, turnip greens) are rich in calcium but little of it is absorbed (kale is best).

Click the icon to see an image of milk and the facial bones.

Mineral-Rich Fruits and Vegetables.

Potassium. Potassium may be very important for strong bones and may help counteract negative effects of high-protein diets. Potassium-rich fruits include bananas, oranges, prunes, and cantaloupes, and vegetables that contain potassium include carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados, and broccoli.
Magnesium. Some studies have observed that low levels of magnesium may contribute to thinning bones. Some studies suggest that magnesium supplements help suppress the cycle that leads to bone loss. Experts recommend 350 mg a day for supplements. However, excessive magnesium may be harmful in people with diabetes or kidney disease. Foods rich in magnesium include dairy products, spinach, potatoes, beets, nuts, sole, and halibut.
Other Minerals. Phosphorous, boron, and zinc have also been associated with bone protection.

Protein. Protein may be important for frail older people for improving muscle strength. Researchers, meanwhile, have associated both low and high protein intake with bone loss. Protein deficiencies appear to trigger hormonal changes that increase bone breakdown. On the other hand, high protein intake increases urinary calcium loss, which can impair bone density in people with low-calcium diets. High-protein diets, however, do not appear to cause bone loss if calcium intake is also high. The bottom line is to eat enough protein but to balance it with plenty of calcium-rich, and other mineral-rich, foods.

The protein source (meat, soy, or fish) may have some effect on bone density, although the effects are not clear. Studies are mixed on whether protein from meat has a positive or negative effect on bone loss. In any case, the best sources of protein for bone protection may be from oily fish or soy.

Choosing protein from fish (especially oily fish such as sardines, salmon, mackerel, fresh tuna, and herring) is a good option. Oily fish are high in vitamin D, which is bone protective. Such fish are also heart protective. Wild salmon has a much higher vitamin D content than farmed salmon. American brands of canned tuna, meanwhile, generally do not contain significant amounts of vitamin D.
Soy may have some modest protection against bone loss. Soy is high in estrogen-like plant chemicals called isoflavones, which may improve bone health in older women. In particular, the isoflavone genistein is being studied for its effects on bone health. A small 2007 study indicated that genistein supplements, when taken with vitamin D and calcium, may help improve bone density in postmenopausal women with thinning bones. (However, other studies indicate that soy has no effect on bone density in healthy premenopausal women.) Soy food products that also contain calcium, such as tofu, may be particularly beneficial. In such cases, 3 ounces of tofu supply 60% of daily calcium requirements.

Alcohol. Alcohol has different effects on bones depending on how much is consumed. One study found that women older than age 65 who drank one to two drinks (1 - 2 oz) of alcohol weekly had higher bone density than non-drinkers. Alcohol in moderate amounts may reduce parathyroid hormone and increase estrogen levels. Excessive drinking, however, has been associated with brittle bones.

Cola, Coffee, Tea and Caffeine. One study suggested that drinking tea regularly may help protect bones. Nevertheless, there has been some concern that caffeine consumption, particularly from coffee, may increase calcium levels in urine and reduce levels in the body. In one trial, consumption of lots of coffee (9 or more cups per day) was associated with an increased risk of hip fractures in women, but not in men. However, not all studies support a risk. Some evidence suggests that caffeine may pose a danger for bone loss only in elderly thin women -- but not in those who have normal or high weight. Drinking carbonated beverages, particularly cola, may increase the risk for bone fractures in people with low bone density.

Everyone who smokes should quit. The risk for osteoporosis from smoking appears to diminish after quitting.

An important component in reducing the risk for fractures is preventing falls. Risk factors for falling include:

Slow walking
Inability to walk in a straight line
Certain medications (such as tranquilizers and sleeping pills)
Low blood pressure when rising in the morning
Poor vision

Recommendations for preventing falls or fractures from falls in elderly people include:

Exercise to maintain strength and balance if there are no conflicting medical conditions. In one study of older people, this was the single best intervention for preventing falls.
Do not use loose rugs on the floors.
Move any obstructions to walking, such as loose cords or very low pieces of furniture, away from traveled areas.
Rooms should be well lit.
Have regular eye checkups.
Try wearing hip pads. Hip pads are specially designed to protect hipbones against falls and are worn under clothing. Evidence on their protection against fractures is weak, however, particularly since compliance is poor. Nevertheless, newer hip pads that are thinner and made with newer materials may be helpful and more appealing.
Wear thinner, hard-soled shoes. Studies indicate these shoes are just as comfortable as the popular resilient-soled footwear, but they may be difficult to find. Soft-soled high-resilient so-called athletic footwear may contribute to impaired balance and dangerous falls, in part, because these cushioned shoes offer less stability.

Medications

Many drugs are available to treat osteoporosis. Unfortunately, studies continue to report that doctors fail to evaluate and adequately treat both men and women for this condition, even after a fracture. According to one study of women over age 60, fewer than 2% were evaluated for osteoporosis or spinal fracture by their doctors. Among those who were diagnosed, only 36% received appropriate medication. Among adults who had sustained fractures, less than 5% of men and fewer than half of women were evaluated and treated according to recommended guidelines, indicated two other studies. In one of the studies, only 24% of women received treatment for osteoporosis after a fracture. In both studies, the older a woman was, the less likely she was to have adequate evaluation or treatment.

Drugs Used to Treat Osteoporosis. Two types of drugs are used to treat osteoporosis:

Antiresorptive Drugs. Antiresorptives include bisphosphonates, hormone replacement therapy, selective estrogen-receptor modulators (SERMs), and calcitonin. Bisphosphonates are the standard drugs used for osteoporosis. These drugs block resorption (preventing bone break down), which slows the rate of bone remodeling, but they cannot rebuild bone. Because resorption and reformation occur naturally as a continuous process, blocking resorption may eventually also reduce bone formation.
Anabolic, or Bone-Forming, Drugs. Drugs that rebuild bone are known as anabolics. The primary anabolic drug is low-dose parathyroid hormone (PTH), which is administered through injections. This medicine is proving to be very effective in restoring bone and preventing fractions. PTH is still relatively new, and long-term effects are still unknown. Fluoride is another bone-building drug, but it has limitations and is not commonly used.

Both types of drugs are effective in preventing bone loss and fractures, although they vary in their effectiveness and safety.

Bisphosphonates are antiresorptive drugs. They are the primary drugs for preventing and treating osteoporosis. They can help reduce the risk of both spinal and hip fractures, including among patients with prior bone breaks.

Studies indicate that these drugs are effective and safe for at least 10 years. Eventually, however, bone loss continues with bisphosphonates. This may be due to the fact that bone breakdown is one of two phases in a continuous process of rebuilding bone. Over time, just blocking resorption will interrupt this process and impair the second half of the process -- bone formation. Some researchers think that this problem may be overcome by building bone for a couple of years with parathyroid hormone (PTH), then following this treatment with bisphosphonates to prevent the breakdown of bone. (Administering the two drugs simultaneously is not effective because bisphosphonates interfere with the way PTH works.)

A 2006 study of the bisphosphonate alendronate (Fosamax), the most widely used osteoporosis drug, indicated that women at low risk for fracture may be able to stop using the drug after 5 years without increasing their fracture risk for another 5 years. However, the Journal of the American Medical Association study also suggested that it is safer for women at high risk for spine fractures to keep taking alendronate on a continuous basis.

Candidates. National Osteoporosis Foundation guidelines recommend that the following people should take or consider bisphosphonates:

Women with a below-normal bone density of 2.5 standard deviation or greater and no history of fractures
Women with below-normal bone density 1 standard deviation or more and a history of fractures

Brands. Bisphosphonates are available in different forms:

Oral bisphosphonates. These pills include alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). Alendronate and risedronate are taken once a week. In 2005, ibandronate was approved as the first once-monthly pill. Risedronate is also available in a pill that contains calcium. Risedronate and alendronate are approved for both men and women.
Injectable bisphosphonates. In 2007, zoledronic acid (Reclast) was approved as the first once-yearly injection treatment for osteoporosis. The injectable form of ibandronate (Boniva), approved in 2006, requires injections 4 times a year. Injectable bisphosphonates are an alternative for patients who may have difficulty swallowing pills or sitting upright after oral bisphosphonate treatment.

Side Effects. The most distressing side effects of bisphosphonates are gastrointestinal problems, particularly stomach cramps and heartburn. These symptoms are very common and occur in nearly half of all patients. Other side effects may include irritation of the esophagus (the tube that connects the mouth to the stomach) and ulcers in the esophagus or stomach. Some patients may experience muscle and joint pain. To avoid stomach problems, doctors recommend:

Take the pill on an empty stomach in the morning with 6 - 8 ounces of water (not juice or carbonated or mineral water).
After taking the pill, remain in an upright position. Do not eat or drink for at least 30 - 60 minutes. (Check your drug’s dosing instructions for exact time.)
If you develop chest pain, heartburn, or difficulty swallowing, stop taking the drug and see your doctor.

Osteonecrosis (bone death) of the jaw is a rare side effect that has occurred mainly in patients who received intravenous bisphosphonates for cancer treatment (not osteoporosis). Many of these patients had major dental procedures before developing osteonecrosis. However, this bone decay condition has also been reported in some patients who have taken bisphosphonates by mouth (mainly alendronate). Symptoms may include jaw pain or swelling, gum infections, and poor healing of the gums. Talk to your doctor or dentist if you experience any jaw or gum discomfort while taking a bisphosphonate drug.

Raloxifene (Evista) belongs to a class of drugs called selective estrogen-receptor modulators (SERMs). These drugs are similar, but not identical, to estrogen. Raloxifene provides the bone benefits of estrogen without increasing the risks for estrogen-related breast and uterine cancers. Raloxifene was approved in 1997 to prevent osteoporosis in postmenopausal women, and in 1999 for the treatment of osteoporosis in postmenopausal women. In 2007, the Food and Drug Administration approved raloxifene for prevention of breast cancer in postmenopausal women with osteoporosis, as well as postmenopausal women at high risk for invasive breast cancer.

While there are many SERM drugs, raloxifene is the only one approved for both treatment and prevention of osteoporosis. Only postmenopausal women who have or are at risk for osteoporosis should take this drug. Studies indicate that raloxifene can stop the thinning of bone and help build better quality and stronger bone.

A thrombus is a blood clot that forms in a vessel and remains there. An embolism is a clot that travels from the site where it formed to another location in the body. Thrombi or emboli can lodge in a blood vessel and block the flow of blood in that location, depriving tissues of normal blood flow and oxygen. This can result in damage, destruction (infarction), or even death of the tissues (necrosis) in that area.

Side Effects. Raloxifene increases the risk for blood clots in the veins. Because of this side effect, raloxifene also increases the risk for stroke (but not other types of heart disease). These side effects, though rare, are very serious. Women should not take this drug if they have a history of blood clots, or if they have certain risk factors for stroke and heart disease. More common mild side effects include hot flashes and leg cramps.

Produced by the thyroid gland, natural calcitonin regulates calcium levels by inhibiting the osteoclastic activity, the breakdown of bone. The drug version is derived from salmon and is available as a nasal spray (Miacalcin) and an injected form (Calcimar). Calcitonin is not used to prevent osteoporosis. It treats osteoporosis. It may be effective for spinal protection (but not hip) in both men and women. Calcitonin may be an alternative for patients who cannot take a bisphosphonate or SERM. It also appears to help relieve bone pain associated with established osteoporosis and fracture.

Side Effects. Side effects include headache, dizziness, anorexia, diarrhea, skin rashes, and edema (swelling). The most common adverse effect experienced with the injection is nausea, with or without vomiting. This occurs less often with the nasal spray. The nasal spray may cause nosebleeds, sinusitis, and inflammation of the membranes in the nose. Also, many people who take calcitonin develop resistance or allergic reactions after long-term use.

Although high persistent levels of parathyroid hormone (PTH) can cause osteoporosis, daily injections of low and intermittent doses of this hormone actually stimulate bone production and increase bone mineral density. In clinical studies, teriparatide (Forteo), a drug made from selected amino acids found in parathyroid hormone, reduced the risk for spinal and non-spinal fractures by 50 - 65%. It may prove to be a very useful drug for men with osteoporosis. Unlike most treatments for osteoporosis, including bisphosphonates, the benefits may persist even after the injections have been stopped.

Although the treatment requires injections, researchers are investigating a nasal spray version of PTH. In addition to easing patient discomfort, there is some preliminary evidence that nasal-administered PTH may be better absorbed than injections. Side effects of PTH are generally mild and include nausea, dizziness, and leg cramps. No significant complications have been reported to date.

Early animal studies did report bone tumors in mice that were given parathyroid long-term. Such effects have not been observed in humans to date. However, people with Paget disease, (a disorder in which bone thickens but also, oddly, weakens), should not take parathyroid hormone, since they are at higher than normal risk for bone tumors.

Hormone replacement therapy (HRT) is sometimes used to prevent osteoporosis. A Women’s Health Initiative (WHI) study found that women who received estrogen, or estrogen plus progestin, therapy had fewer fractures than women who received placebo.

However, WHI studies have also shown that estrogen increases the risk for breast cancer, blood clots, strokes, and heart attacks. For this reason, women need to balance the benefits that HRT has on bone-loss protection, with the risks it carries for other serious health conditions. The Food and Drug Administration recommends that women first try other medications for prevention of osteoporosis.

HRT is available in many different forms, including pills and skin patches. [See In-Depth Report #40: Menopause.]

New SERMs. Bazedoxifene (Viviant) is a new selective estrogen receptor modulator (SERM) that is in phase III clinical trials. In research presented at the 2007 annual meeting of the American Society for Bone and Mineral Research (ASBMR), bazedoxifene reduced new cases of non-spine fracture by 52% compared to placebo.
Biologic Drugs. Denosumab is a humanized monoclonal antibody injectable drug currently in phase III studies. It targets the RANK ligand, a protein involved with cells that break down bone (osteoclasts). Results presented at the 2007 ASBMR meeting indicated that denosumab may help increase bone mineral density by as much as 10.6%. Odanacatib is another biologic drug showing promise in phase IIB trials. Odanacatib inhibits cathepsin K, a protein that also plays a role in osteoclast activity.
Strontium. Strontium, a chemical element found in bone, may help increase bone formation and decrease bone resorption. NB S101 is a strontium drug currently in phase II trials.

Treatment

Nonsurgical treatments for fractures include braces, plaster cases, and manipulation of the fracture. Such approaches have not been well studied to determine an optimal method, and patients should discuss all options with their doctors.

Reconstructive surgery is usually used for hip fractures and should be performed within 48 hours, assuming the patient has no other complicating medical conditions. After surgery, the patient should be mobilized within the first day. In one study, protein supplements helped people with hip fractures recover more quickly and reduced bone loss.

Percutaneous vertebroplasty and kyphoplasty are surgical procedures used to lessen pain. Research to date suggests that they are safe and provide pain relief for many patients. In some cases they may increase height. There have been few controlled trials, however, and more research is needed to determine long-term effects.

Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into damaged vertebrae. It is proving useful for stabilizing the spine and relieving pain in patients with spinal compression fractures due to osteoporosis or cancer. Success rates of over 90% have been reported. Serious complications occur in fewer than 1% of cases.

Kyphoplasty. Kyphoplasty is a variant of percutaneous vertebroplasty that may help prevent kyphosis (hunchback) in patients whose spines have collapsed. The procedure inserts a balloon into the fractured vertebrae. As the balloon inflates, the spine is moved upward, to its original location. The balloon is then removed, and the bone and the core of the newly-erect vertebrae are filled with cement. In one 2003 study, short-term symptom relief improved by 70% and was immediate. Long-term effectiveness is not yet known.

Resources

www.nof.org -- National Osteoporosis Foundation
www.niams.nih.gov/Health_Info/Bone -- National Institutes of Health, Osteoporosis and Related Bone Diseases
www.menopause.org -- North American Menopause Society
www.asbmr.org -- American Society for Bone and Mineral Research
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases

References

Agency for Healthcare Research and Quality. Effectiveness and Safety of Vitamin D in Relation to Bone Health, Structured Abstract. August 2007. Rockville, MD.

Bilezikian JP. Osteonecrosis of the jaw -- do bisphosphonates pose a risk? N Engl J Med. 2006 Nov 30;355(22):2278-81.

Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007 May 3;356(18):1809-22.

Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, et al. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006 Dec 27;296(24):2927-38.

Diem SJ, Blackwell TL, Stone KL, Yaffe K, Haney EM, Bliziotes MM, et al. Use of antidepressants and rates of hip bone loss in older women: the study of osteoporotic fractures. Arch Intern Med. 2007 Jun 25;167(12):1240-5.

Haney EM, Chan BK, Diem SJ, Ensrud KE, Cauley JA, Barrett-Connor E, et al. Association of low bone mineral density with selective serotonin reuptake inhibitor use by older men. Arch Intern Med. 2007 Jun 25;167(12):1246-51.

Marini H, Minutoli L, Polito F, Bitto A, Altavilla D, Atteritano M, et al. Effects of the phytoestrogen genistein on bone metabolism in osteopenic postmenopausal women: a randomized trial. Ann Intern Med. 2007 Jun 19;146(12):839-47.

Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007 Aug 25;370(9588):657-66.

Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006 Dec 27;296(24):2947-53.

Review Date:
11/1/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Kidney stones

FitSugar — Wed, 08 Oct 2008 17:35:35 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Symptoms
Diagnosis
Treatment
Medications
Other Treatments
Complications
Prevention
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

New Research:

Patients who have the most common type of gastric bypass surgery, the Roux-en-Y, are at increased risk for kidney stones, beginning 6 months after surgery, according to a study published in 2006.

Causes of Kidney Stones:

Calcium stones form when there is an imbalance in the urine substances that promote and block the formation of stones. Often, the cause of this imbalance is unknown.
Having acidic urine or too much uric acid in the body leads to the formation of uric acid stones.
Struvite stones are almost always caused by urinary tract infections due to bacteria that produce certain enzymes.
Other stones, including cystine and xanthine stones, are usually due to genetic abnormalities.

Treatments:

In about 85% of patients, the kidney stones are small enough that they pass through normal urination, usually within 2 - 3 days.
Certain medications can prevent recurrence of stones in people who are at high risk.
Extracorporeal shock wave lithotripsy (ESWL) is a technique that uses sound waves (ultrasound) to break up simple stones in the kidney or upper urinary tract. The shock waves are delivered from outside the body.
Surgery may be necessary if the stone or stones are too big to pass, and cannot be broken down through ESWL.
A change of diet and increased drinking of fluids, especially water, will help prevent a recurrence.

Introduction

Kidney stones are hard, solid rocks that form in the urinary tract. In many cases, the stones are very small and can pass out of the body without any problems. However, if a stone (even a small one) blocks the flow of urine, excruciating pain may result, and prompt medical treatment may be needed.

The process of urination begins in the kidneys. The kidneys filter out fluids and waste from the body, producing urine. The two kidneys are located deep behind the abdominal organs, below the ribs and toward the middle of the back.

Each kidney contains over a million nephrons. These are the tiny filtration units of the kidney.
Each nephron is composed of a tiny group of blood vessels (a glomerulus) enclosed in a funnel-like structure called Bowman's capsule.
Each glomerulus filters waste products, water, and salts out of the liquid part of the blood (plasma) that has entered the kidney.
About 1% of the plasma is converted into urine. The rest returns into the blood to prevent dehydration. Urine is primarily made of acids, urea, and creatinine (nitrogen compounds).
Urine passes from Bowman's capsule into tiny tubules, which lead to large collecting tubes in the center of the kidney. As the urine passes through this network, it becomes more concentrated.
Urine then flows from the kidney through thin tubes called ureters into the bladder.
The bladder's stretchy walls expand to store the incoming urine until it leaves the body through a tube called the urethra.

The kidneys are responsible for removing wastes from the body, regulating electrolyte balance and blood pressure, and stimulating red blood cell production.

Click the icon to see an image of the urinary tract.

Occasionally, various salts build up on the inside surfaces of the kidney and form crystals. Eventually these crystals become large enough to form stones in the kidney, a condition called nephrolithiasis. Kidney stones (renal calculi) may also form in the ureter or the bladder. Combinations of minerals and other chemicals, some derived from a person's diet, make up the salts in these stones.

Click the icon to see an image of the kidney stones.

Calcium Stones. About 70 - 90% of all kidney stones are made of calcium, usually combined with oxalate, or oxalic acid. A number of common vegetables, fruits, and grains contain oxalate.

About 6% of calcium stones are made of calcium phosphate (called brushite).

Uric Acid Stones. Uric acid is responsible for close to 10% of kidney stones. It is the breakdown product of purines, nitrogen compounds found in our bodies and in certain foods. The breakdown of purines to uric acid occurs in the liver, and from there uric acid enters the bloodstream, most of it passing into the kidneys. From the kidneys, uric acid leaves the body in the urine. Often, uric acid stones occur with calcium stones.

Struvite Stones. Struvite stones are made of magnesium ammonium phosphate. They are almost always associated with certain urinary tract infections. Worldwide, they make up to 30% of all kidney stones. In the United States, however, less than 15% of all stones are struvite. Most struvite stones occur in women. The rate of these stones may be declining in America, perhaps because of better control of urinary tract infections.

Cystine Stones. A build-up of the amino acid cystine, a building block of protein, causes 1% of kidney stones in adults and up to 8% of stones in children. The tendency to form these stones is inherited. Cystine stones are marked by rapid growth and recurrence, which, if not treated promptly, can eventually lead to kidney failure.

Xanthine Stones. Other kidney stones are composed of xanthine, a nitrogen compound. These stones are extremely uncommon and usually occur as a result of a rare genetic disorder.

Click the icon to see an animation about kidney stones.

Causes

The key process in the development of kidney stones is supersaturation.

The urine carries salts, including calcium oxalate, uric acid, cystine, or xanthine.
These salts can become extremely concentrated if there is not enough urine, or if unusually high amounts of crystal-forming salts are present.
When salt concentration levels reach the point at which they no longer dissolve, these salts form crystals.

Different factors may be involved in either reducing urine amount, or increasing the levels of the salts.

Deficiencies in Protective Factors. Normally, urine contains substances that may protect against stone formation, including:

Magnesium
Citrate
Pyrophosphate
Enzymes

These substances:

Allow salt in the urine to be at higher-than-normal concentrations without forming crystals
Prevent crystal formation
Coat the crystals and prevent them from sticking to the surface of kidney tubes

Not having enough of these protective substances can cause stones.

Changes in the Acidity of the Urine. Changes in the acid balance of the urine can affect stone formation.

Uric acid and cystine stones mainly form in acidic urine.
Calcium phosphate and struvite stones increase in alkaline urine.

Factors that Bind Crystals to the Kidney Tubules. Researchers are studying the cells lining the kidney tubules in order to understand how and why early crystals bind to the tubes long enough to form stones. Under investigation are elevated levels of substances that either cause crystals to stick to the tubes or deficiencies in those that prevent them from sticking.

In general, calcium stones form when there is an imbalance in the urine substances that promote and block the formation of stones. Often, the cause of calcium stones is not known, and the condition is then called idiopathic nephrolithiasis. Research suggests that nearly all stones result from problems in the breakdown and absorption of calcium and oxalate. Genetic factors may play a role in about half of these cases. A number of medical conditions and drugs can also affect digestion and intestinal absorption.

Excess Calcium in the Urine (Hypercalciuria). Hypercalciuria (too much calcium in the urine) is responsible for as much as 70% of calcium-containing stones. A number of conditions may produce hypercalciuria. Many are due to genetic factors, but most cases are idiopathic (due to unknown causes).

The following can lead to hypercalciuria and calcium stones:

Too much calcium absorption in the intestines: In most of these conditions, genetic factors lead to increased calcium absorption in the intestine. Researchers are investigating a possible defective gene that regulates calcitriol, a form of vitamin D, which, in excess levels, may increase intestinal absorption of calcium.
Excessive chloride: Chloride has a negative charge, and calcium has a positive one, so they balance each other in the body. Excess chloride may lead to excess calcium. A gene known as CLCN5, which regulates chloride in the urine, is defective in many patients with calcium stones.
Renal calcium leak: In this condition, the filtering processes in the kidney fail, causing an increase of calcium in the urine.
Excessive sodium: High urinary levels of sodium result in increased levels of calcium. Certain defects in the kidney tubules transport system, which cause imbalances in sodium and phosphate, can lead to high calcium levels in the urine. A diet high in salt can also produce this effect.

Excess Oxalate in the Urine (Hyperoxaluria). Oxalate is the most common stone-forming compound. Excessive oxalate in the urine (hyperoxaluria) is responsible for up to 60% of calcium stones and is a more common cause of stones than too much calcium in the urine.

Hyperoxaluria can be either primary or secondary.

Primary hyperoxaluria is an inherited disorder in which too much oxalate in the urine is the main problem.
Secondary hyperoxaluria results from specific conditions that cause high levels of urinary oxalate.

Secondary hyperoxaluria is usually caused by too much dietary oxalates (found in a number of common vegetables, fruits, and grains) or by problems in the body's breakdown of oxalates. Such defects may be due to various factors:

Severe vitamin B6 deficiencies (usually due to genetic disorders)
Deficiencies in Oxalobacter formigene, an intestinal bacteria that breaks down oxalate
Short bowel syndrome, a condition that makes the intestines unable to properly absorb fat and nutrients; calcium may bind to unabsorbed fat instead of oxalates, which causes a buildup of oxalate
Androgens (male hormones)

Female hormones (estrogens) actually lower the risk of hyperoxaluria. Estrogen may help prevent the formation of calcium oxalate stones by keeping urine alkaline, and raising protective citrate levels.

A study published in 2006 found that patients who undergo the most common gastric type of bypass surgery, the Roux-en-Y, were at increased risk for calcium oxalate kidney stones, beginning 6 months after surgery. The study found that patients who underwent the procedure developed hyperoxaluria, and the condition was common 12 months after surgery. The authors also noted an increased number of kidney stone incidents in this patient group.

Excessive Calcium in the Bloodstream (Hypercalcemia). Hypercalcemia generally occurs when bones break down and release too much calcium into the bloodstream. This is a process called resorption. It can occur from a number of different diseases and events:

Hyperparathyroidism: Overactive parathyroid glands cause about 5% of calcium stones. People with this disorder have at least a 20% chance of developing kidney stones. Women are more likely to have this disorder than men.
Immobilization: Lack of movement can lead to kidney stones.
Renal tubular acidosis: This disorder causes acidic and alkaline imbalance. Renal tubular acidosis not only increases calcium levels in the bloodstream but also reduces protective citrate levels.

Hyperuricosuria is a condition of high levels of uric acid in urine. It occurs in between 15 - 20% of people (mostly men) with calcium oxalate stones. Urate, the salt formed from uric acid, creates the center of a crystal (nidus), around which calcium oxalate crystals form and grow. Such stones tend to be severe and recurrent. They appear to be strongly related to a high intake of protein. (Hyperuricosuria also plays a major role in some uric acid stones.)

Low Urine Levels of Citrate (Hypocitraturia). Citrate is the main substance in the body that is responsible for removing excess calcium. It also blocks the process that turns calcium crystals into stones. Low levels of citrate in the urine (hypocitraturia) is a significant risk factor for calcium stones. In addition, hypocitraturia also increases the risk for uric acid stones. This condition most likely contributes to about a third of all kidney stones.

Many conditions can reduce citrate levels. Some causes include:

Renal tubular acidosis
Potassium or magnesium deficiency
Urinary tract infection
Kidney failure
Chronic diarrhea

Often, however, the cause of hypocitraturia-related stones is unknown.

Low Levels of Other Stone-Blocking Compounds. Several other compounds in the urine, including magnesium and pyrophosphate, also prevent the formation of calcium stones. If any of these compounds are lacking, stones may develop.

Nanobacteria Infection. Nanobacteria are tiny infectious organisms that can pass from the blood into urine. They coat themselves with mineral deposits that resemble the composition of kidney stones. Cells infected with these bacteria develop mineral deposits on the inside and outside. Researchers believe that nanobacteria may form the cores of the kidney stones in many people.

Human body tissues, certain foods, and certain alcoholic drinks contain substances called purines. Purine-containing foods include dried beans, peas, and liver. When the body breaks down purines, it produces uric acid. The presence of a certain level of uric acid in the body is normal.

The following conditions are usually seen in patients with uric acid stones:

Too much acid in the urine for a long period (the most important cause of uric acid stones)
Lower than normal amounts of urine produced.
Hyperuricosuria, a metabolic disorder that leads to high levels of uric acid in the urine

Note: Hyperuricosuria can also trigger calcium stones. Therefore, a combination of calcium and uric acid stones may be present in patients with hyperuricosuria.

A number of conditions and other factors may contribute to, or cause, uric acid stones:

Gout: Uric acid and other kidney stones develop in up to 25% of patients with primary gout, a painful form of arthritis that occurs when uric acid in the blood forms crystals in one or more joints.
Diabetes: New research has shown that people with type 2 diabetes have highly acidic urine that can lead to kidney stones, particularly uric acid stones. The findings were published in the May 2006 Journal of the American Society of Nephrology.
Insulin resistance: People with insulin resistance are at an increased risk for uric acid stones. The reason is unknown but may be related to the transport of certain salts through the kidneys. This transport changes in patients with insulin resistance.
Kidney abnormalities: Kidney problems that reduce the production of ammonia, particularly in people with diabetes or insulin resistance, may lead to uric acid stones.
Genetic factors: Genetic factors can increase a person's risk for uric acid stones.
Hypocitraturia: Hypocitraturia is a low amount of citrate in the urine.
Diet: Eating too much animal protein increases the risk of forming uric acid stones.

Other risk factors include:

Certain medications (chemotherapy drugs, diuretics, and salicylates)
Binge drinking
Not eating for long periods of time (fasting)
Lead poisoning
Blood cancers (leukemia, multiple myeloma, and lymphomas)
Some rare types of anemia (low levels of red blood cells in the blood)
Chronic diarrhea

Struvite stones are almost always caused by urinary tract infections due to bacteria that produce certain enzymes. These enzymes raise the concentration of ammonia in the urine. Ammonia makes up the crystals that form struvite stones. The stone-promoting bacteria are usually Proteus, but may also include Pseudomonas, Klebsiella, Providencia, Serratia, and staphylococci. Women are twice as likely to have struvite stones as men.

Other stones, including cystine and xanthine stones, are usually due to genetic abnormalities.

Causes of Cystine Stones. Cystine stones develop from genetic defects that cause abnormal transport of amino acids in the kidney and gastrointestinal system leading to a build-up of cystine, one of these amino acids. Researchers have identified two genes responsible for this condition: SLC3A1 and CLC7A9.

Causes of Xanthine Stones. In some cases, xanthine stones may develop in patients being treated with allopurinol for gout.

Risk Factors

Kidney stones are one of the most common disorders of the urinary tract. They are an ancient health problem. Evidence of kidney stones has been found in an Egyptian mummy estimated to be more than 7,000 years old.

An estimated 1.3 million Americans seek medical help for kidney stones each year. At this time, studies suggest kidney stones affect over 5% of Americans and that the rate has increased since the 1970s, perhaps because of increases in animal and dietary protein intake.

Men. The risk of kidney stones increases in a man's 40s and continues to rise until age 70. Caucasian men are at higher risk than other groups.

Women. The risk of kidney stones peaks in a woman's 50s. In younger women, stones are more likely to develop during the late stages of pregnancy. Pregnant women tend to have a higher calcium intake, but their kidneys do no handle the calcium as well as they did prior to pregnancy. Kidney stones are still a rare occurrence during pregnancy, however, affecting only 1 in 1,500 pregnancies.

Risk Factors in Children. Stones in the urinary tract in children are usually due to genetic factors. Most of the time, the cause is too much calcium in the urine (hypercalciuria). Deformities in the urinary tract pose a significant risk for kidney stones in children. Children with low birth weight who need to be fed intravenously are also at risk for stones.

Obesity and weight gain are both associated with an increased risk of kidney stones.

Men who weigh more than 220 lbs are 44% more likely to develop kidney stones than men who weigh less than 150 lbs.
Women who are obese are 90% more likely to develop kidney stones than women with a lower body mass index (BMI).

Higher BMIs and larger waist circumferences are both risk factors for kidney stones. Researchers think that there may be a link between fat tissue, insulin resistance, and urine composition. People with larger body sizes may excrete more calcium and uric acid, which increase the risk of kidney stone formation.

A family history of kidney stones increases one's risk for the condition. Researchers are looking into markers or other factors that might predict kidney stones in relatives, although none has yet been clearly identified. One report found that among the siblings of patients with calcium stones, sisters with higher urinary calcium levels and more acidic urine were more likely to develop stones. Brothers with high urinary calcium, low urinary potassium, and older age were more likely to have the problem. A family history of gout may also make a person vulnerable to stones.

According to a 2003 study of American ethnic groups, Caucasians have the highest incidence of kidney stones (5.9%) followed by Mexican Americans (2.6%). African-Americans have the lowest risk (1.7%).

Dietary factors, minerals in local water, or both may contribute to geographic differences that have been observed in the occurrence of kidney stones. Studies have reported the highest occurrence of kidney stones in the southern region of the United States and the lowest in the west. One study suggested that the higher risk may be due to a higher rate of high blood pressure in the southern states and certain dietary habits, particularly lower intake of magnesium and low use of calcium supplements.

Specific Foods. In general, certain foods increase the risk for stones only in people who have genetic or medical vulnerability. People whose diets are high in animal protein and low in fiber and fluids may be at higher risk for stones. A number of foods contain oxalic acid, but there is no proof that such foods make any major contribution to calcium oxalate stones in people without other risk factors. However, several studies have shown that increasing dietary calcium and restricting salt, animal protein, and foods rich in oxalate can help prevent calcium oxalate stones from returning.

Stress. One study reported that people who had a major, stressful life experience were more likely to develop stones than those who had not. Some experts speculate that this increased risk may be due to a hormone called vasopressin, which is released in response to stress. Vasopressin also increases the concentration of urine.

Sleep Position. Sleeping in the same position consistently may influence risk. A 2001 study reported that in people who had a history of kidney stones, recurrences tended to occur on the same side that people slept on. An earlier study suggested that people who had kidney stones were more apt to sleep on their stomachs. Movement during sleep did not appear to affect the risk.

Being Bedridden. Any medical or physical condition that keeps a person in bed or immobile increases blood levels of calcium from bone breakdown, thereby posing a risk for stone formation.

Gout. Patients with gout are at a high risk of uric acid stones. These patients have very acidic urine, and a 2002 study suggested that the two disorders may have a common source.

High Blood Pressure. Persons with high blood pressure are up to three times more likely to develop kidney stones. It is not entirely clear whether having high blood pressure increases the risk for a stone, whether stones lead to high blood pressure, or if there is an action linking both.

Inflammatory Bowel Disease: Crohn's disease and ulcerative colitis cause problems in absorption of substances in the intestines. These problems significantly increase the risk for kidney stones, particularly in men.

Urinary Tract Infections (UTIs): Urinary tract infections are almost always the cause of struvite stones.

Hyperparathyroidism: The parathyroid glands regulate calcium levels in the body through the parathyroid hormone. In hyperparathyroidism, one or more of these glands makes too much parathyroid hormone. Some people with hyperparathyroidism develop kidney stones. Surgery to remove the hyperactive parathyroid gland in such patients reduces the risk for stone formation, but the risk still remains high for some time after surgery.

Other Medical Conditions. Kidney disease, chronic diarrhea, certain cancers (such as leukemia and lymphoma), and sarcoidosis put people at higher risk for stones.

AIDS medications. Over 10% of persons with AIDS who take the medicine indinavir develop stones. The risk is even higher in patients with AIDS who also have hepatitis B, hepatitis C, or hemophilia, as well as those who are very thin or who take the antibiotic combination TMP-SMX. In one study of persons with AIDS who took a combination of indinavir, zidovudine, and lamivudine, 36% developed kidney stones.

Other Drugs. Kidney stones are a rare side effect of thyroid hormones and loop diuretics (drugs that increase urination). In fact, diuretics are also used to prevent calcium stones. Certain cancer chemotherapies can also cause kidney stones. Long-term use of medications, such as antacids, which change the acidic content of urine, may increase the risk for kidney stones.

Symptoms

In many cases, kidney stones do not produce symptoms. However, if a stone becomes stuck in the ureter (the thin tube between the bladder and the kidney), symptoms can be very severe. Often, they vary depending on the stone's location and its progress.

Kidney stone attacks tend to be most common late at night or in the early morning, possibly because of minimal urine output or constriction of the ureters during the early morning hours. Kidney stone attacks are least common during the late afternoon

Pain usually begins abruptly on one side and then usually continues as intense, constant pain. (In some cases it persists for a few minutes, disappears, and then returns after about 10 minutes.)
The patient cannot become comfortable and usually stands, sits, paces, or reclines in a vain search for a position that will bring relief.
If the stone is in the kidney or upper urinary tract, the pain usually starts in one flank area (to the side of the back near the waist). It typically moves to the groin as the stone passes down.
If the stone is too large to pass easily, the pain follows the muscle contractions in the wall of the ureter as they try to squeeze the stone along into the bladder.
Nausea and vomiting may occur.
Blood in the urine may be present.
As the stone passes down the ureter closer to the bladder, a person may feel the need to urinate more often or a burning sensation during urination.
If fever and chills accompany any of these symptoms, an infection may be present.

The size of the stone does not necessarily predict the severity of the pain; a very tiny crystal with sharp edges can cause intense pain while a larger round stone may not be as distressing. Struvite stones can often occur without symptoms.

Diagnosis

The doctor will perform a physical exam. This includes pressing against abdominal areas for tender locations that might indicate the presence of the stone.

The patient's age is a significant factor. Kidney stones that occur in children and young patients are more apt to result from inherited problems that cause cystine, xanthine, or, in some cases, calcium oxalate stones. In adult patients, calcium stones are most common.

A medical history may help predict which crystal has formed the stone. The doctor will need to know the following:

Any previous kidney stone attacks
Histories of cancer, sarcoidosis, or small bowel disease
Any medications being taken, including non-prescription substances, particularly high doses of vitamins D or C and calcium-containing antacids

Many conditions can cause symptoms similar to kidney stones. Usually the diagnosis is easily made because of the specific nature of the symptoms, but it is not always clear. Urinary tract infections can cause similar, but usually less intense, pain. In fact, infection may be present with a kidney stone. Other causes of pain that may mimic kidney stones include:

Gallstones
Diverticulitis (infection or irritation of abnormal pockets in the intestines)
Intestinal blockage
Blood clots
Irritable bowel syndrome
Appendicitis
Stomach ulcers
Hiatal hernia (when the upper part of the stomach bulges into the chest, through an opening in the diaphragm)
Pancreatitis (inflammation of the pancreas)
Hepatitis
Pelvic inflammatory disease
Inflammatory bowel disease (Crohn's and colitis)
Heart attack

Various imaging techniques are helpful in determining the presence of kidney stones. The best approach uses spiral (or helical) computed tomography scans. If it is not available, the patient will need ultrasound or standard x-rays. If no stones show up, but the patient has severe pain that suggests the presence of kidney stones, the next step is an intravenous pyelogram.

X-Rays. A standard x-ray of the kidneys, ureters, and bladder may be a good first step for identifying many stones, since many are visible on x-rays. Calcium stones can be identified on x-rays by their white color. Cystine crystals can also show up on x-rays.

Spiral (or Helical) Computed Tomography. A type of computed tomography (CT) scan, called a spiral or helical CT scan, is currently the best method for diagnosing stones in either the kidneys or the ureters. This test is fast, does not require instruments or foreign chemicals to enter the body, and provides detailed accurate images of even very small stones. If stones are not present, a spiral CT scan can often identify other causes of pain in the kidney area. It is better than x-rays, ultrasound, and intravenous pyelogram -- the previous standard test for detecting kidney stones. Experts hope spiral CT will eventually be able to identify the chemicals present in a stone.

Ultrasound. Ultrasound can detect clear uric acid stones and obstruction in the urinary tract. It is not useful for finding very small stones, but some research indicates that it may be a useful first diagnostic step in the emergency room to help predict the likelihood of a stone, including suspected stones in children.

Intravenous Pyelogram. With intravenous pyelogram (IVP), the doctor injects a special dye into the patient. A technician will then take x-rays as the dye enters the kidneys and travels down the urinary tract. IVP is invasive but, until recently, was the most cost-effective method for detecting stones. Where it is available, spiral CT is now preferred, since it gives a faster diagnosis, is more accurate, is safer, and is similar in cost.

In any case, IVP should not be used on patients with kidney failure. There is also a risk for an allergic reaction to standard dyes, although newer less allergenic ones are becoming available.

In the procedure intravenous pyelogram (IVP), the patient is injected with dye. X-rays are taken as the dye travels through the urinary tract. This procedure is done to confirm the presence of kidney stones, although some stones may be too small to see.

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) techniques are showing promise for diagnosing urinary tract obstruction but do not yet accurately reveal small stones, or ones that do not cause a blockage. Because no radiation is involved with MRI, however, it may prove to be a good option for pregnant women.

Urine samples are required to evaluate features of the urine, including its acidity and the presence of:

Red or white blood cells
Infection
Crystals
High or low levels of chemicals that inhibit or promote stone formation

Clean-Catch Urine Sample for Culturing. After determining that a kidney stone is present, the health care provider usually gives the patient a collection kit, including filters, to try to catch the stone or gravel as it passes out. The urine may also be tested (cultured) for the presence of infection-causing organisms. A clean-catch urine sample is almost always required for culturing. To provide a clean catch, do the following:

First, wash your hands thoroughly, then wash the penis or vulva and surrounding area four times with downward strokes, using a new soapy sponge each time.
Begin urinating into the toilet and stop after a few drops.
Position the container to catch the middle portion of the urine stream. Ideally, this urine will contain only the bacteria and other evidence of the stone.
Urinate the remainder into the toilet.
Tighten the cap on the container securely, being careful not to touch the inside of the rim.

Click the icon to see an image of a calcium urine test.

Twenty-Four Hour Urine Collection. A 24-hour urine collection may be needed to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatinine.

You should not change any of your usual eating or drinking patterns when performing this test.
Discard the first urination on the day of the test.
Afterward all urine passed over the next 24 hours is collected, including the first urination on the morning of day two.
A second 24-hour urine collection may be needed to determine if treatment is working or if the first analysis was not conclusive and the doctor suspects a less common stone, such as a cystine or xanthine stone.

Click the icon to see an image of a uric acid urine test.

Urine tests that are used to determine the specific chemical and biological factors causing the stone should be performed about 6 weeks after the attack, since the attack itself may change the levels of such substances, including calcium, phosphate, and citrate. It should be noted that calcium levels in the urine may be abnormal even in many people without stones. In addition, high urinary concentrations of calcium may pose a greater or lesser risk depending on age. (In one 2001 study, middle-aged adults with high urinary calcium concentrations had a much greater risk than older adults with high levels.)

The kidney stones obtained from the urine sample are examined under a microscope. The crystal formations are often specific enough so that the doctor is able to identify the substance causing the stone.

Calcium oxalate crystals are eight-sided, while calcium phosphate crystals tend to have irregular shapes.
Uric acid stones are sometimes described as pear-shaped or diamond-shaped.
Some struvite stones have very specific shapes commonly described as "coffin lids." Struvite crystals may also occur in a formation known as a staghorn, which can be large and damaging to the kidney.

Testing whether urine is acidic or alkaline helps to identify the specific type of stone. The levels of acidity or alkalinity in any solution, including urine, are indicated by the pH scale:

A pH value of 7.0 is neutral.
A solution with a low pH (below 7.0) is acidic. (A low pH favors uric acid and cystine stones.)
A solution with a high pH is alkaline. (A high pH favors calcium phosphate and struvite stones.)

A dipstick test for blood in the urine (called hematuria) is typically performed when patients appear in the emergency room with flank pain (the primary symptom of kidney stones). About a third of kidney stone patients, however, do not show blood in the urine, so other tests may be needed.

Blood Tests for Stone Factors. Blood and urine tests help determine what substances form the crystals. This allows the doctor to determine the appropriate treatment and preventive measures.

Blood tests may help determine blood levels of urea nitrogen, creatinine, calcium, phosphate, and uric acid for patients with known or suspected calcium oxalate stones. Doctors will usually schedule these tests about 6 weeks after the attack, in order to measure these substances when the stone has been passed, and the patient has been stabilized. This is particularly true in patients with recurrent stones.

Parathyroid Tests. Tests to detect parathyroid hormone levels are given if the doctor suspects hyperparathyroidism, based on other signs and symptoms.

Tests for Infection. A test result that shows a high white blood cell count might indicate infection. Such results, however, could be misleading, since the number of white blood cells could also increase in response to the extreme physical stress of a kidney stone attack.

Tests for Metabolic Problems. About half of children with stones have an identifiable metabolic disorder, which increases their risk of stone recurrence five-fold. Experts argue whether tests for metabolic disorders are routinely needed once the stone composition has been determined. Studies suggest the following:

People with recurrent calcium stones have a wide range of irregular blood or urine test results, indicating a variety of possible metabolic disorders. For example, calcium stones in middle-aged women may be due to parathyroid abnormalities.
Calcium phosphate stones most likely result from renal tubular acidosis.
People with non-calcium stones generally have identifiable metabolic disorders.
Determining the stone composition may be sufficient for treatment, and may help avoid unnecessary metabolic tests.

Treatment

When tests show there is a kidney stone, the next step is to determine treatment. The patient should be admitted to the emergency room if they have severe vomiting, fever, or symptoms of infection.

Strong opioid painkillers, such as meperidine (Demerol), are often required for a severe kidney stone attack. However, doctors will usually not give such drugs until they confirm the presence of a kidney stone on an x-ray. In some cases, powerful nonsteroidal anti-inflammatory drugs (NSAIDs) may work just as well as opioids, and they have fewer side effects. However, they do take longer to work.

In about 85% of patients, the kidney stones are small enough that they pass through normal urination, usually within 2 to 3 days. In some cases, a stone may take weeks to months to pass, although pain usually goes away before that.

The patient should drink plenty of water (two to three quarts a day) to help move the stone along, and take painkillers as needed. The doctor usually provides a collection kit with a filter and asks the patient to save any passed stones for testing.

If the stone has not passed in 2 - 3 days, the patient will need additional treatments. In some severe cases, hospitalization may be necessary.

Specific procedures vary depending on the size of the stone or complexity of the situation. Noninvasive procedures are proving to be very beneficial in eliminating stones, and have largely replaced invasive surgeries.

For small stones that are lodged in the lower part of the ureter, ureteroscopy or shock wave lithotripsy are the procedures of choice.
For larger stones, ureteroscopy, percutaneous nephrolithotomy, and shock wave lithotripsy are all potentially useful. The choice of any of these procedures depends on a number of factors, including location of the stone and the presence of any problems that caused the stone in the first place.
In some complicated cases, standard open surgical procedures (called nephrolithotomy) may be required.

See "Other Treatments" section for more information on kidney stone surgery.


Stone Type	Diet and Lifestyle	Medications	Procedures
Calcium Oxalate	Plenty of fluids. (Choose water, lemon juice. Avoid grapefruit, apple, and cranberry juice.) Limit the amount of protein and salt in the diet. Increase fiber. Limit the amount of fats in the diet, particularly in people who have short bowel syndrome. Balance normal calcium intake with potassium- and phosphate-rich foods. Limit the amount of calcium in the diet (only in people who have genetic abnormalities that cause high intestinal absorption of calcium). Limit the amount of foods high in oxalates (only in patients with rare intestinal conditions that cause hyperoxaluria).	Diuretics ("water pills"), Citrate salts, phosphates, cholestyramine.	Lithotripsy, uteroscopy, percutaneous nephrolithotomy, open surgery.
Uric Acid	Plenty of fluids. (Choose water, blackcurrant juice. Avoid cranberry juice.) Increase calcium intake (be sure well-balanced with potassium and phosphates). Reduce protein and other foods with high-purine content.	Potassium citrate, sodium bicarbonate, allopurinol.	Lithotripsy, uteroscopy, percutaneous nephrolithotomy, open surgery.
Struvite stones	Plenty of fluids (water, cranberry juice). Reduce proteins.	Antibiotics to eliminate any infection. Acetohydroxamic acid (AHA) may be helpful in combination with antibiotics. In some cases, organic acids given through urinary tract.	May respond poorly to most lithotripsy procedures and require open surgery. Newer procedures may be helpful.
Cystine stones	Very high fluid intake (four quarts a day). Limit the amount of protein in the diet.	Alkalizing agents (such as bicarbonate). Sometimes d-penicillamine, tiopronine, or captopril useful for lowering cystine levels.	May respond poorly to most lithotripsy procedures and require open surgery. Newer procedures may be helpful.

Medications

Diuretics. Diuretics are medicines commonly used to treat high blood pressure and other disorders. They remove fluid and sodium from the body. Low doses of a class of diuretics known as thiazides are sometimes used to reduce the amount of calcium released by the kidneys into the urine. Thiazides include:

Hydrochlorothiazide (Esidrix, HydroDiuril)
Chlorothiazide (Diuril)
Trichlormethiazide (Metahydrin, Naqua)
Chlorthalidone (Hygroton)

However, thiazides also cause potassium loss, which reduces citrate levels and can increase the risk for stones. Patients taking thiazide pills should also take potassium citrate, to prevent citrate loss. Amiloride (Midamor) is a potassium-sparing diuretic, which may be used if a thiazide does not work.

Citrates. Citrate salts are often given to people with calcium oxalate or uric acid stones:

Potassium magnesium citrate is available over the counter. It is proving to be very beneficial in preventing kidney stones. In one study, potassium magnesium citrate reduced the risk for kidney stone recurrence by 85%.
Potassium citrate (K-Lyte, Polycitra-K, Urocit-K) is given as the only treatment to people with normal urine calcium levels. Between 70 - 75% of patients with recurrent stones have ongoing remission (no stone recurrence) with potassium citrate treatment. However, some people cannot tolerate potassium citrate because of side effects (stomach problems).
Magnesium citrate (Citroma, Citro-Nesia) may help people who develop calcium stones from impaired intestinal absorption due to short bowel disease.

None of these products should be used by people with struvite stones, urinary tract infections, bleeding disorders, or kidney damage. Patients who take citrate supplements containing potassium should not take any other medications that either contain this mineral or prevent its loss (such as so-called potassium-sparing diuretics). People with peptic ulcers should avoid citrate supplements, or discuss using non-tablet forms with their doctor.

Phosphates. Phosphates help reduce the breakdown of bone that releases calcium into the bloodstream. They are also involved in the kidney's reabsorption of calcium from the urine.

Phosphate compounds:

Neutral (nonacidic) sodium or potassium phosphate (K-Phos, Neutral, Neutra-Phos) is usually taken four times a day after meals to prevent kidney stones unless otherwise directed by the doctor. Diarrhea is a possible side effect.
Cellulose phosphate (Calcibind) is recommended only for severe hypercalciuria that is associated with recurrent calcium stones and is caused by excessive absorption of calcium from the intestines. However, this drug may increase oxalate levels and decrease magnesium levels, which can lead to different stones. Taking magnesium supplements and reducing dietary oxalates, calcium, and ascorbic acid may help offset these risks. Cellulose phosphate may also cause bloating.

Avoid acidic forms of phosphate, since they increase the risks for both hypocitraturia and hypercalciuria.

Cholestyramine (Questran, Questran Light) is a drug used to reduce cholesterol levels. However, it also binds with oxalate in the intestine, so it is also used to reduce high oxalate levels in urine (hyperoxaluria). The drug usually comes in a powder that is dissolved in liquid.

Bloating and constipation are common side effects of this drug. Cholestyramine also interferes with other medications, including digoxin (Lanoxin) and warfarin, and may contribute to calcium loss and osteoporosis. In order to prevent such interactions, take other drugs 1 hour before, or 4 - 6 hours after, taking cholestyramine.

Long-term use of cholestyramine may cause deficiencies of vitamins A, D, E, and K. Vitamin supplements may be necessary.

Sodium Bicarbonate. Patients whose persistently acidic urine causes uric acid stones may take sodium bicarbonate to reduce urine acidity. Patients taking sodium bicarbonate must test their urine regularly with pH paper, which turns different colors depending on whether the urine is acidic or alkaline. Too much sodium bicarbonate can cause the urine to become too alkaline. This increases the risk for calcium phosphate stones. Patients who need to reduce the amount of sodium they take in (as a result of other medical conditions) should not use sodium bicarbonate.

Potassium Citrate. Potassium citrate, which restores citrate to the urine, is useful for patients with high levels of uric acid in the urine.

Allopurinol. Allopurinol (Lupurin, Zyloprim) is very effective in reducing high levels of uric acid, and may be helpful for patients with uric acid stones. Allopurinol will not prevent calcium stones from forming. There is also a slight risk for the formation of xanthine stones with this drug. Side effects include diarrhea, headache, and fever. More severe complications include blood disorders that may produce fatigue, bleeding, or bruising. The drug may also increase the risk for cataracts.

About 2% of patients experience an allergic reaction to allopurinol that causes a rash. In rare cases, the rash can become severe and widespread enough to be life threatening. Allergic individuals who have experienced only a mild rash to sodium bicarbonate may be able to build up their tolerance for allopurinol by undergoing a desensitization process. In this process, patients start with small doses of allopurinol and gradually increase them, if no reaction develops.

Allopurinol reduces uric acid levels rapidly, so it may trigger an attack of gout in vulnerable people. To prevent this problem, patients taking allopurinol should also take a nonsteroidal anti-inflammatory drug (NSAID) for 2 or 3 months. Aspirin should not be taken, since it increases uric acid levels. Patients should discuss the appropriate NSAID choice with their doctor.

Before patients can receive any medical treatment for struvite stones, they must have surgery to completely remove the stones.

Antibiotics for Eliminating Infection. Persons with struvite stones receive ongoing treatment with antibiotics to keep the urine free of the bacteria that cause urinary tract infections. Careful follow-up and urine testing is extremely important. A high-pH urine indicates low acidity and an increased risk of infection.

Acetohydroxamic Acid (AHA). Acetohydroxamic acid (AHA or Lithostat) is beneficial when used with long-term antibiotics. AHA blocks enzymes that bacteria release, and has been effective in preventing stones even when bacteria are present. Side effects, however, can be severe. The drug reduces iron levels in the body, so anemia is a common problem. Patients may need to take iron supplements. Other side effects include nausea, vomiting, depression, anxiety, rash, persistent headache, and, rarely, small blood clots in the legs.

Experts recommend this drug only for patients with healthy kidneys who have chronic diseases caused by specific struvite-causing organisms.

Patients taking this medicine should avoid alcohol. Pregnant women should not take acetohydroxamic acid.

Organic Acids. Medical treatments to dissolve stones may be useful in patients who do not respond to other medications, or in combination with surgeries. Acidic urine dissolves struvite stones, so the doctor may wash the urinary tract with a solution of organic acids (such as Renacidin). Candidates for such washes must have sterile urine (no bacteria or other organisms in the urine) and healthy kidney function. In surgical patients, the wash is performed 4 or 5 days after the operation. The wash starts with saline (salt solution) for 1 - 2 days and, if there are no problems, the organic acid solution follows for another 1 or 2 days, until all stones dissolve. Regular urine tests are necessary to ensure that the bacteria do not return.

Aluminum Hydroxide Gel. An aluminum hydroxide anti-acid gel may reduce phosphate levels that are important in struvite stone formation, but it has a long-term risk of causing aluminum toxicity. Long-term reduction of phosphorus can also increase the risk for calcium oxalate stones. Experts recommend limiting phosphorus through a low-protein diet, rather than through the use of this gel.

The first-line treatment for cystine stones is increasing the alkalization of urine so the stones can dissolve. If alkalization fails, drug treatments may include d-penicillamine, alpha-mercaptopropionylglycine (tiopronine), or captopril. These medications lower cystine concentration.

Patients with cystine stones must drink plenty of fluids, much more than patients with other stones. The patients should drink at least four quarts of water over a 24-hour period.

Other Treatments

Surgery is usually needed if the stone is too large to pass on its own, if there are signs that the stone is growing, or if the stone is blocking the urine flow and causing a urinary tract infection or kidney damage.

Until recently, the procedure to remove a stone was a very painful, major surgery, requiring 4-6 weeks of recovery. Today, treatments for stones are much less invasive. Major surgery is performed in less than 2% of patients.

Stone removal procedures:

Extracorporeal shock wave lithotripsy (ESWL) is used for small stones (less than one centimeter, or slightly less than half an inch) that occur in the upper part of the ureter and do not pass on their own. One study indicated lithotripsy might even be safe and effective for patients whose stones are associated with malformed kidneys, although such patients are at higher risk for stone recurrence and should be carefully monitored.
Percutaneous nephrolithotomy (PNL). PNL can be used for very large stones in the upper urinary tract, when ESWL fails, for kidney transplant patients, or when the kidneys or surrounding areas are malformed. PNL is the preferred procedure for drug-resistant cystine stones, which are usually also resistant to shock wave therapy.
Ureteroscopy. For stones in the lower tract, ureteroscopy is generally the best procedure, although lithotripsy is also usually feasible and patients ordinarily prefer it.
Standard open surgery (nephrolithotomy) may be required if any of these procedures fail or are not appropriate, or in special cases, such as when the patient is very obese.

Most procedures are more effective for calcium and uric acid stones and less effective for struvite and cystine stones, although new techniques may be improving their effects on all stones.

Extracorporeal shock wave lithotripsy (ESWL) is a technique that uses sound waves (ultrasound) to break up simple stones in the kidney or upper urinary tract. ("Extracorporeal" means "outside the body," and "lithotripsy" means stone-breaking.) ESWL is not used for cystine stones. The procedure generally does not work for stones larger than three centimeters in diameter (which is slightly over an inch). There are several variations of ESWL. The following is a typical procedure:

Most ESWL procedures use some anesthesia, although they are often done on an outpatient basis.
The patient is positioned in a water bath. (In some procedures the patient lies on a soft cushion.)
The procedure uses ultrasound to generate shock waves that travel through the skin and body tissues until they hit the dense stones. (The doctor pinpoints the stone during treatment by using x-rays or ultrasound.)
The shock waves crush the stones into tiny sand-like pieces that usually pass easily through the urinary tract.
The shattered stone fragments may cause discomfort as they pass through the urinary tract. In such cases, the doctor may insert a small tube called a stent through the bladder into the ureter to help the fragments pass. This practice, however, has not proved to speed up passage of the stones in most cases and is not used routinely.

Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to shatter simple stones in the kidney or upper urinary tract. Ultrasonic waves are passed through the body until they strike the dense stones. Pulses of sonic waves pulverize the stones, which are then more easily passed through the ureter and out of the body in the urine.

Success rates of ESWL range from 50 - 90%, depending on the location of the stone and the surgeon's technique and level of experience. Recovery time is short, and most people can resume normal activities in a few days.

Complications. Complications may include the following:

The most common complication is blood in the urine, which lasts for a few days after treatment. To reduce the chances of bleeding, doctors usually tell patients to avoid taking aspirin and other NSAIDs, which can promote bleeding, for 7 - 10 days before the treatment.
Bruising and minor discomfort due to the shock waves are common in the back or abdomen.
Sometimes the stone does not completely break up with one treatment, and additional treatments may be required. Inability to pass stone fragments may also be a particular problem in patients who have cysts or other kidney problems.
Higher risk for diabetes later. A 2006 study published in the journal Urology found that 17% of patients who received shock-wave lithotripsy developed diabetes later in life. The diabetes risk was related to the number and intensity of shocks.
Higher risk for hypertension (high blood pressure). The same study that linked ESWL to diabetes also showed that people who received shock-wave lithotripsy treatment were 47% more likely to develop high blood pressure than those who had their stones treated without surgery.

ESWL appears to be safe for children, although a 2001 study reported temporary damage in the kidney tubules after treatment. It is unclear if this complication has any long-term consequences. Experts recommend using the least amount of shocks and impact possible in young people. If more than one treatment is needed, there should be a waiting period of at least 15 days between treatments.

Percutaneous nephrolithotomy may be used when ESWL is not available or effective (such as if the stone is very large, in an inaccessible location, or is a cystine stone). It is also preferred over ESWL for stones that have remained in the ureter for more than 4 weeks.

It is more effective than ESWL for patients with severe obesity, and appears to be safe for the very elderly and the very young. Success rates are nearly 98% for kidney stones and 88% for ureteral stones. They may vary by the technique used and the specific patients. For example, success rates are slightly lower in children, although the procedure can be done safely in young patients. Long-term effects are unknown.

A typical procedure is as follows:

The surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney.
The surgeon then inserts an instrument called a nephroscope through the tunnel.
The stone is located and removed. If it is large, it is destroyed using ultrasound, lasers, or other devices. The surgeon then removes the fragments. An advantage of percutaneous nephrolithotomy over ESWL is that the surgeon is able to remove the stone fragments directly, instead of relying on their natural passage from the kidney.
Generally, patients stay in the hospital for 5 or 6 days and may need a small device called a nephrostomy tube left in the kidney during the healing process.

Devices Used to Destroy Stones. For large stones, some type of energy-delivering device may be needed to break the stone into small pieces. They are referred to as intracorporeal lithotripsy devices (meaning stone breakers within the body). The device may be one of the following:

Ultrasound is currently the preferred method. It results in a stone-free rate of 94%. A rigid nephroscope delivers the ultrasound waves.
Pneumatic (compressed air) lithotripsy uses a probe that comes in direct contract with a stone. Compressed air causes a piston to collide rapidly with the probe, and the result is a "jackhammer" action against the stone, causing the stone to break up. This method, however, can send stone fragments into other parts of the urinary tract.
A more recent device uses a combination pneumatic probe and ultrasound, with stone-free rates of 80 - 89%. It may prove to be superior to ultrasound alone and be effective against stones of all types.
The holmium laser literally melts the stones and destroys up to 100% of stones of any composition. It uses a flexible nephroscope and has an excellent safety record. It should be used sparingly, however, with particular caution against large uric acid stones until more is understood about its effect. Another device, the erbium: YAG laser, although showing promise in lithotripsy, is not currently practical.

Complications. Complication rates are about 3%. Major complications occur in about 1% of cases. These complications may include scarring of the tissue, but studies indicate that it does not impair kidney function, even if the patient requires repeat surgery. There is also a risk for blood loss during and after the procedure, which, in some cases, can be significant.

Because the procedure requires large volumes of fluid, fluid overload is a potential problem, particularly in children or patients with heart disease.

In some cases, infection may result. Other complications may include a collapsed lung and injuries to areas outside the kidney (but within the operative area), such as the abdomen or chest.

Ureteroscopy may be used for stones in the middle and lower ureter. With the arrival of smaller instruments, this procedure can be done successfully in children as well. The procedure involves the following:

The patient receives a general anesthetic, though no incision is required for the procedure.
The surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter.
The surgeon locates the stone or stones.
The surgeon can remove smaller stones by grasping them with small forceps. A laser or pneumatic device breaks up large stones.
The surgeon may decide to leave a small tube, or stent, in the ureter for a few days after treatment, to help the lining of the ureter heal.

Complication rates range from 10 - 20%, with major problems occurring in up to 6% of patients. In some cases, large stones are not broken up into small enough pieces. This can result in blockage of the urinary tract and possible kidney damage.

Imaging tests, such as ultrasound or spiral CT, are useful within 3 months to check for residual stones, and a second procedure may be required. The risk of complications is highest when the procedure is performed by less experienced surgeons, or if stones are found in the kidney. The risk for perforation of the ureter increases the longer the procedure takes.

Open surgery involves incisions through the patient's flank and into the kidney. The surgeon will cool the kidneys using ice. X-rays during the procedure help locate the stone. At the beginning of the surgery, the surgeon will isolate the arteries supplying the kidneys, ensuring they are not harmed during the surgery. The surgeon will then locate and remove the stone. The surgeon will also correct any blockage in the affected area. The surgery, called nephrolithotomy, is very invasive and is restricted to the following:

Patients with very large or complex stones that cannot be removed using less invasive measures
Very obese patients

Some centers report success with extracorporeal shock wave lithotripsy, however, in patients who would normally be nephrolithotomy candidates. Therefore, even these patients should discuss other options with their surgeon.

The procedure is not appropriate for patients with:

Bleeding or clotting disorders
Untreated widespread infection
Severe and chronic kidney insufficiency (unless removing the stone will improve kidney function)

Complications

Between 70 - 90% of crystals remain tiny enough so that they can travel through the urinary tract and leave the body in the urine without being noticed. When they do cause symptoms, however, kidney stones have been described as one of the most painful disorders to afflict humans. The pain they cause is sometimes called renal colic. ("Renal" means "kidney.")

Obstruction and Infection. Although kidney stones often lead to obstruction (blockage) of the urinary tract, the blockage is usually temporary and causes no lasting damage. In some cases, however, particularly if the obstruction progresses with no symptoms, infection may occur, which can be serious and need immediate attention.

Kidney Failure. It is very rare for kidney stones to cause kidney failure, although some people have risk factors that make them more vulnerable to this serious complication. Risk factors include the following:

Very frequent recurrences (such as in people with cystine stones or other inherited forms of kidney stone disorders)
Accompanying episodes of urinary tract infections with obstruction, a particular risk with struvite stones
A history of multiple urologic procedures for kidney stones
Greater size of the kidney stone gravel

Without preventive treatment, calcium stones recur in 10% of patients within a year of the first attack, and in half of patients within 5 - 7 years. Individual risk for recurrence, however, varies depending on the stone and the underlying condition. For example, a 15-year-old with inherited cystine stones has a very high risk for recurrence, while a middle-aged man with a first calcium oxalate stone has a good chance of never passing another.

Prevention

All individuals who have experienced kidney stones should take some specific preventive measures to prevent recurrence. The following are some general observations:

The most important dietary recommendations for reducing the risk for calcium stones are increasing fluid intake, restricting sodium, and reducing protein intake.
A lower risk for calcium stones is also associated with higher potassium intake.
A high calcium diet does not appear to increase the risk for kidney stones as long as it also contains plenty of fluids and dietary potassium and phosphate. (Increasing calcium alone may pose a modest risk for stones.)
Patients should try to correct any dietary habits that cause acidic or alkaline imbalances in the urine, which promote stone formation.

Because different kidney stone types may require specific dietary changes, patients should work with their doctors to develop an individualized plan. It is important to note that nutritional considerations are very important in preventing recurrence, and patients should be vigilant in complying with the proper diet.

Good voiding habits, particularly frequent urination, are important. Therefore, of all the preventive recommendations, drinking enough fluids is the most important guideline for people with any type of kidney stones.

In general, patients with calcium or uric acid stones should drink at least 10 full glasses of fluid each day (at least half should be water). This includes one with each meal and drinking fluids at night, even if it means getting up from sleep. Fluid intake should produce at least two and a half quarts of urine each day.
To prevent cystine stones, patients should drink even more water -- over a gallon, or 16 8-ounce cups, every day. Patients should drink this amount at regular intervals throughout the night and day.

In all cases, patients need more fluid after exertion and during times of stress. If they drink enough, the urine should be pale and almost watery, not dark and yellow.

Water. Although water is best, it may vary depending on its source. Variations in water itself may have different impacts. One study reported that drinking hard tap water increased urinary calcium concentration by 50% compared to soft bottled water. On the other hand, mineral water containing both calcium and magnesium may reduce several risk factors for both calcium and uric acid stone formation.

Juices and Specific Effects. Other beverages have various positive or negative effects, depending on the type of stone:

Lemon Juice: Drinking one-half cup of pure lemon juice (enough to make eight glasses of lemonade) every day raises citrate levels in the urine, which might protect against calcium stones. (While orange juice also increases citrate levels, it does not lower calcium and it raises oxalate levels. Therefore, it is not recommended.)
Cranberry and Apple Juice: Apple and cranberry juice contain oxalates, and both have been associated with a higher risk for calcium oxalate stones. Cranberry juice has properties that may increase the risk for both calcium oxalate and uric acid stones. On the other hand, cranberry juice helps prevent urinary tract infections and so may be helpful for reducing the risk for struvite and brushite stones. (These stones are far less common, however.)
Black Currant Juice: In one study, black currant juice reduced urine acidity and was associated with protection against uric acid stones.
Grapefruit Juice: A number of studies have found a risk for stones from drinking grapefruit juice. In one study, just one 8-ounce cup of grapefruit juice per day increased the risk for forming stones by 44%.

Other Beverages and Their Effects on Stone Formation.

Soft Drinks. Patients with stones should avoid cola drinks, since they can severely reduce citrate levels in the urine. Many soft drinks contain phosphoric acid, which increases the risk for stones. Some research shows that drinking one quart (less than three 12-ounce cans) of soda per week may increase a person's risk of developing stones by 15%.
Alcohol. Wine may be protective against kidney stones. A study conducted in Finland, suggests that the risk of developing stones also decreases with beer consumption. However, it is important to remember that beer is high in oxalates. Beer and other alcoholic beverages also contain purines, which may increase the specific risk for the less common uric acid stones in susceptible people. Binge drinking, in any case, increases uric acid and the risk for stones.
Coffee and Tea. Some research reported a lower risk for stones in people who drink tea and both regular and decaffeinated coffee.

A long-term 2002 study followed men with calcium oxalate stones and high levels of urinary calcium. The study found that a low-sodium, low-protein diet, containing normal levels of calcium, dramatically reduced the recurrence of stones compared to a diet that was simply low in calcium.

Salt Restriction. Because salt intake increases the amount of calcium in urine, patients with calcium stones should limit their sodium intake. Sodium may also increase levels of urate, the crystalline substance that can trigger formation of recurrent calcium oxalate stones. Although the relative contribution of limiting sodium intake has not been confirmed, some researchers believe that restricting sodium along with increasing fluid intake is the most important dietary measure for preventing stones.

Protein Restriction. Protein increases uric acid, calcium, and oxalate levels in the urine, and reduces citrate levels. Diets high in protein, particularly meat protein, have been consistently connected with kidney stones. (Meat protein has a higher sulfur content and produces more acid than vegetable protein.) A 2002 study of those following a high-protein, low-carbohydrate diet (such as the Atkins diet, for example), found dramatically increased levels of urinary uric acid and calcium after just several weeks. These effects put patients at higher risk for not just kidney stones, but possibly osteoporosis as well. According to Swiss studies, about a third of people at risk for calcium stones may have a sensitivity to meat proteins that causes mild hyperoxaluria.

Whether restricting meat protein alone has any protective value without restricting sodium as well is unknown. Most studies to date have found no difference in stone development between people with low and normal meat protein diets over four years. A 2000 study reported that only dramatic reductions in meat protein had any preventive effect against stone recurrence.

Although the precise role of dietary protein in kidney stones needs further clarification, it is reasonable for everyone to consume meat protein in moderation. People with struvite stones, who need to reduce phosphates in their diets, should also cut down on proteins.

Calcium from Foods. Dietary calcium recommendations for kidney stone prevention need to be determined on an individual basis. A doctor will suggest calcium guidelines based on a patient's age, gender, body size, and type of stone. Most studies indicate that dietary calcium (found in milk, yogurt, and cheese) protects against many types of calcium oxalate stones. Large studies of both men and women found that those with the highest intake of calcium from foods had a much lower risk for stones than those who had little calcium in their diets. A diet containing a normal amount of calcium, but reduced amounts of animal protein and salt, may protect against stones better than a low-calcium regimen. However, calcium metabolism changes as people age. Some studies suggest that a high calcium intake protects against kidney stones in men younger than age 60, but not in older men.

Dietary calcium may actually bind the oxalate in foods, preventing it from being absorbed into the blood and excreted into the urine. In a normal healthy diet, dairy products supply almost 80% of the daily calcium requirement. For people who have calcium stones associated with resorption (the breakdown of bone that releases calcium into the bloodstream), limiting calcium intake could cause further bone loss.

Calcium Supplements. Evidence on calcium supplements is mixed, although in general many studies suggest that they reduce oxalate levels and so help prevent calcium oxalate stones. One study suggested that taking 500 mg of calcium supplements a day regularly may "reprogram" the intestines to absorb less calcium and may therefore be protective. Experts generally agree that calcium supplementation within dosage recommendations (about 1,200 mg per day) remains safe. In one study, however, women who took calcium supplements had a 20% higher risk for stones. Research indicates that dosages of calcium above 2,000 mg per day are clearly associated with the formation of stones. Some experts speculate that this higher risk may occur because supplements are often taken in the morning, either without food or with breakfast, which is typically low in oxalates. Taking supplements with later meals may not produce the same risk.

Calcium Restriction in Certain Cases. Some patients, such as those whose stones are caused by genetic defects in which the intestine absorbs too much calcium, may need to limit calcium intake. More studies are needed to define this group precisely.

Fiber may be beneficial for people with kidney stones. In addition, some fiber-rich foods may contain compounds that help protect against kidney stones. A wide variety of high-fiber plant foods contain a compound called phytate (also called inositol hexaphosphate, InsP6, or IP6), which appears to help prevent crystallization of calcium salts, both oxalate and phosphate. Phytate is found in legumes and wheat and rice bran. (Soybeans are also rich in phytate but they are also very high in oxalates, so the overall effects of soy on kidney stones are not clear.)

A high intake of purines can increase the amount of uric acid in the urine. Those at risk for uric acid stones should reduce their intake of foods and beverages that contain purines. These include beer and other alcoholic beverages, anchovies, sardines, yeast, organ meats (such as liver and kidneys), legumes (including dried beans, peas, and soybeans), mushrooms, spinach, asparagus, cauliflower, and poultry.

Most people with calcium oxalate stones should not avoid oxalate-rich foods unless the doctor specifically recommends a restrictive diet. Oxalate binds with calcium in the intestine, which may actually reduce calcium absorption. Some studies, in fact, indicate that eating foods containing oxalates and calcium together may reduce the risk of stones. Most of the foods that contain oxalates are very important for good health. Limiting oxalates may be particularly harmful in people with bowel disorders marked by malabsorption.

Foods high in oxalic acid include beets, soy, beet tops, black tea, chenopodium, chocolate, cocoa, dried figs, ground pepper, lamb, lime peel, nuts, parsley, poppy seeds, purslane, rhubarb, sorrel, spinach, and Swiss chard.
Foods containing moderate amounts of oxalates include beans (green and wax), blackberries, blueberries, carrots, celery, coffee (roasted), concord grapes, currants, dandelion greens, endive, gooseberries, lemon peel, okra, green onions, oranges, green peppers, black raspberries, strawberries, and sweet potatoes.

Certain fats may play a beneficial or harmful role in specific cases of kidney stones.

Restricted Fats in Patients with Stones Associated with Bowel Disease. Patients who have stones associated with short-bowel syndrome should eat foods with lower amounts of fats and oxalates. If patients with short-bowel syndrome eat too much fat, calcium may bind to unabsorbed fat instead of to oxalates. This increased oxalate levels, resulting in increased risk of stone formation.

Fish Oil. Omega-3 fatty acids, found in oily fish like mackerel, salmon, and albacore tuna, have many health benefits, but the most current evidence suggests they do not help prevent kidney stones. A 2005 study of over 200,000 adults found that increased omega-3 fatty acid intake did not reduce kidney stone risk.

Vitamin B6. Vitamin B6, or pyridoxine, is used to treat people with primary hyperoxaluria, a severe inherited disorder. Patients should not try to treat themselves with vitamin B6. Very high doses (500 to 2,000 mg daily over long periods) can cause nerve damage, with loss of balance and numbness in the feet and hands. Food sources of vitamin B6 include meats, oily fish, poultry, whole grains, dried fortified cereals, soybeans, avocados, baked potatoes with skins, watermelon, plantains, bananas, peanuts, and brewer's yeast.

Vitamin C. Ascorbic acid (vitamin C) may change in the body to tiny crystals, called oxalates. These crystals do not dissolve. People with hyperoxaluria (too much oxalate in the urine) should avoid vitamin C supplements. Even for men with normal oxalate levels, higher consumption of vitamin C (more than 1,000 mg a day) may increase kidney stone risk.

Magnesium and potassium may help reduce the risk for kidney stones in men.

Because of an association between stress and kidney stones, relaxation and stress management techniques may also be beneficial.

Dietary Considerations. People with kidney stones appear to be more sensitive to certain foods than people who do not form kidney stones. Therefore, vulnerable people should make specific changes in their diet. They should work with their doctors to develop a dietary plan that fits their individual situation. Drinking plenty of fluids is important for preventing recurrence of any kidney stone.

Indications for Drug Treatments. If dietary treatments fail, drug therapy may be helpful. A number of drugs are available to prevent recurrences of calcium oxalate and other stones. Medications that inhibit the formation of stones include allopurinol, thiazide, potassium citrate, and potassium-magnesium citrate. In addition, drug treatments can sometimes also help prevent other complications related to stones, such as osteoporosis.

Correcting Underlying Conditions Known to Cause Kidney Stones. It is also important to treat and correct, if possible, any underlying disorder that may be causing stones to form. Such disorders include distal renal tubular acidosis, hyperthyroidism, sarcoidosis, and certain cancers. To prevent calcium stones that form in hyperparathyroid patients, a surgeon may remove the affected parathyroid gland (located in the neck). In most cases, only one of the glands is enlarged. Removing it ends the patient's problem with kidney stones.

Resources

www.kidney.niddk.nih.gov -- National Kidney and Urologic Diseases Information Clearinghouse
www.urologyhealth.org -- American Urological Association
www.kidney.org -- National Kidney Foundation
www.ohf.org -- Oxalosis and Hyperoxaluria Foundation

References

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Taylor EN, Stampfer MJ, Curhan GC. Fatty acid intake and incident nephrolithiasis. Am J Kidney Dis. 2005;45(2):267-274.

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Review Date:
7/24/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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