FitSugar

Know your A, B, Cs: Riboflavin

FitSugar — Fri, 01 Dec 2006 02:00:00 -0800

How many times have you seen Riboflavin listed as an ingredient and thought "another food additive." Well it is not. Riboflavin is the scientific name for vitamin B2.

Like other B vitamins, Riboflavin aids in the production of metabolizing food by converting carbs into sugar which is burned to produce energy. B2 joins forces with the other B vitamins to break down fats and protein. It also promotes healthy skin, hair and nails and general good health.

Riboflavin is also used as food coloring because of its bright yellow-orange hue. It is the culprit for turning your pee that intense yellow if you take a multi-vitamin, which you should consider since the body does not store riboflavin.

Spinach and asparagus are both high in B2s as are milk, cheese, almonds, yeast and liver – does any one out there eat liver anymore? I am truly curious.

Wondering how much of Riboflavin you need - the RDA for adult women is 1.2 mg and a cup of spinach contains about 25% of your daily need. Worried that you are not getting enough of it? Signs of deficiency include cracked and red lips, inflammation of the lining of mouth and tongue, mouth ulcers, cracks at the corners of the mouth, and bloodshot or itchy eyes.

Carbetapentane/diphenhydramine/phenylephrine (By mouth)

admin — Thu, 04 Sep 2008 20:11:33 -0700

Overview

Introduction
Brand Name(s)
When This Medicine Should Not Be Used
How to Use This Medicine
How to Store and Dispose of This Medicine
Drugs and Foods to Avoid
Warnings While Using This Medicine
Possible Side Effects While Using This Medicine

HEALTH GUIDE REFERENCE FROM A.D.A.M

Introduction

Carbetapentane, Diphenhydramine (dye-fen-HYE-dra-meen), Phenylephrine (fen-il-EF-rin)

Relieves cough and stuffy nose caused due to allergies and sinusitis.

Brand Name(s)

Dytan-CS, D-Tann CT, D-Tann CD, Dytan-CD

There may be other brand names for this medicine.

When This Medicine Should Not Be Used

You should not use this medicine if you have had an allergic reaction to carbetapentane, diphenhydramine, or phenylephrine. This medicine should not be given to women who are breast feeding. Do not give any over-the-counter (OTC) cough and cold medicine to a baby or child under 2 years old. Using these medicines in very young children might cause serious or possibly life-threatening side effects.

How to Use This Medicine

Liquid, Chewable Tablet, Tablet

Your doctor will tell you how much of this medicine to use and how often. Do not use more medicine or use it more often than your doctor tells you to.
Measure the oral liquid medicine with a marked measuring spoon, oral syringe, or medicine cup.

If a dose is missed:

If you miss a dose or forget to use your medicine, use it as soon as you can. If it is almost time for your next dose, wait until then to use the medicine and skip the missed dose. Do not use extra medicine to make up for a missed dose.

How to Store and Dispose of This Medicine

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
Ask your pharmacist, doctor, or health caregiver about the best way to dispose of any leftover medicine after you have finished your treatment. You will also need to throw away old medicine after the expiration date has passed.
Keep all medicine away from children and never share your medicine with anyone.

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Make sure your doctor knows if you are using an MAO inhibitor such as Eldepryl®, Marplan®, Nardil®, or Parnate®.
Do not drink alcohol while you are using this medicine.
Tell your doctor if you are using any medicines that make you sleepy. These include sleeping pills, cold and allergy medicine, narcotic pain relievers, and sedatives.

Warnings While Using This Medicine

Make sure your doctor knows if you are pregnant or breast feeding.
Make sure your doctor knows if you have asthma, glaucoma, high blood pressure, heart disease, or an overactive thyroid. Tell your doctor if you have an enlarged prostate, stomach ulcers, or trouble urinating.
This medicine may make you dizzy or drowsy. Avoid driving using machines or doing anything else that could be dangerous if you are not alert.

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing.
Change in how much or how often you urinate.
Chest tightness.
Fast or pounding heartbeat.
Lightheadedness.
Numbness, tingling, or burning pain in your hands, arms, legs, or feet.
Tremor or seizures.
Unusual bleeding, bruising, or weakness.

Call your doctor right away if you notice any of these side effects:

Blurred vision.
Headache.
Mild skin rash or itching.
Mild nausea, vomiting, or mild stomach pain.
Nervousness, restlessness, or trouble sleeping.

Review Date: 8/4/2008

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

Source Doc: 45_5446

Ascorbic acid (Injection)

admin — Thu, 04 Sep 2008 20:06:52 -0700

Overview

Introduction
Brand Name(s)
When This Medicine Should Not Be Used
How to Use This Medicine
How to Store and Dispose of This Medicine
Drugs and Foods to Avoid
Warnings While Using This Medicine
Possible Side Effects While Using This Medicine

HEALTH GUIDE REFERENCE FROM A.D.A.M

Introduction

Ascorbic Acid (a-SKOR-bik AS-id)

Treats and prevents scurvy (lack of vitamin C in your body). This medicine also helps wound healing in fractures and burns.

Brand Name(s)

Ortho/CS, Cenolate, Ascor L NC, Ascor L 500, Mega-C/A Plus

There may be other brand names for this medicine.

When This Medicine Should Not Be Used

You should not use this medicine if you have had an allergic reaction to ascorbic acid.

How to Use This Medicine

Injectable

A nurse or other trained health professional will give you this medicine.
You may be taught how to give your medicine at home. Make sure you understand all instructions before giving yourself an injection. Do not use more medicine or use it more often than your doctor tells you to.
Your doctor will prescribe your exact dose and tell you how often it should be given. This medicine is given as a shot under your skin, into a muscle, or into a vein.

How to Store and Dispose of This Medicine

Throw away used needles in a hard, closed container that the needles cannot poke through. Keep this container away from children and pets.
Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
Keep all medicine away from children and never share your medicine with anyone.
Ask your pharmacist, doctor, or health caregiver about the best way to dispose of any outdated medicine or medicine no longer needed.

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Make sure your doctor knows if you are on salt restricted diet.
Make sure your doctor knows if you are taking any blood thinners such as warfarin (Coumadin®).

Warnings While Using This Medicine

Make sure your doctor knows if you are pregnant or breast feeding.
Let your doctor know if you have diabetes or kidney disease or if you are prone to kidney stones.
Make sure any doctor or dentist who treats you knows that you are using this medicine. This medicine may affect the results of certain medical tests.

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing.
Dizziness or fainting.

If you notice these less serious side effects, talk with your doctor:

Irritation at the site of injection.

Review Date: 8/4/2008

A.D.A.M. Copyright

adam.com

Source Doc: 45_5081

Benzoyl peroxide/clindamycin (On the skin)

admin — Thu, 04 Sep 2008 20:06:14 -0700

Overview

Introduction
Brand Name(s)
When This Medicine Should Not Be Used
How to Use This Medicine
How to Store and Dispose of This Medicine
Drugs and Foods to Avoid
Warnings While Using This Medicine
Possible Side Effects While Using This Medicine

HEALTH GUIDE REFERENCE FROM A.D.A.M

Introduction

Benzoyl Peroxide (BEN-zoe-ill per-OX-ide), Clindamycin (klin-da-MYE-sin)

Treats severe acne.

Brand Name(s)

Benzaclin, Duac, Duac CS

There may be other brand names for this medicine.

When This Medicine Should Not Be Used

You should not use this medicine if you have had an allergic reaction to benzoyl peroxide, clindamycin, or lincomycin. You should not use this medicine if you have an intestinal disorder such as ulcerative colitis. You should not use this medicine if you have ever had severe diarrhea caused by antibiotics.

How to Use This Medicine

Gel/Jelly

Your doctor will tell you how much of this medicine to use and how often. Do not use more medicine or use it more often than your doctor tells you to.
This medicine is for use on the skin only. Do not get it in your eyes, nose, or mouth. Do not use it on skin areas that have cuts or scrapes. If it does get on these areas, rinse it off right away.
Wash your hands with soap and water before and after using this medicine.
Before applying this medicine, wash your skin gently with warm water and pat it dry.
Apply a thin layer to the affected area. Rub it in gently.

How to Store and Dispose of This Medicine

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
Ask your pharmacist, doctor, or health caregiver about the best way to dispose of the used medicine container and any leftover medicine after you have finished your treatment. You will also need to throw away old medicine after the expiration date has passed.
Keep all medicine away from children and never share your medicine with anyone.

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Do not use cosmetics or other skin care products on the treated skin areas.
Tell your doctor if you are using any other medicine for the treatment of acne.
Make sure your doctor knows if you are also using erythromycin (such as Ery-tab® or E-Mycin®).
Make sure your doctor knows if you are using any other topical skin treatments such as skin peeling agents.

Warnings While Using This Medicine

Make sure your doctor knows if you are pregnant or breast feeding.
If you have severe diarrhea, ask your doctor before taking any medicine to stop the diarrhea.
Do not use this medicine for a skin problem that has not been checked by your doctor.
This medicine can cause irritation. Do not get this medicine into your eyes, nose, or mouth.
Make sure your doctor knows if you have any fungal infection of your skin while using this medicine.
This medicine may make your skin more sensitive to sunlight. Use a sunscreen when you are outdoors. Avoid sunlamps and tanning beds.
Do not apply the medicine to your hair or to any colored fabric. This medicine may cause bleaching.

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing.
Severe diarrhea.

If you notice these less serious side effects, talk with your doctor:

Dry skin, rash, itching or peeling skin.
Irritation of your skin where the medicine is applied.
Sunburn.

Review Date: 8/4/2008

A.D.A.M. Copyright

adam.com

Source Doc: 45_5035

How-To: Alphabet Abs With Medicine Ball

FitSugar — Tue, 04 Aug 2009 03:30:23 -0700

Lying on the ground doing crunches might help you tone your upper six-pack, but you also need to strengthen your abs standing, because that's how you use them in your daily activities. Here is a great ab and core exercise, and all you need is a medicine ball and to know how to write your A, B, Cs. There are two variations.

To start: Grab a medicine ball that's between five and 15 pounds. Stand with your feet shoulder-width apart, making sure your knees are not locked.

For stability: Start with the ball at chest level, and slowly write the cursive alphabet in front of you. While your arms move around in all sorts of angles, you need to use your abs to keep your torso still. Think of keeping the area between your ribs and pelvis solid. For a more advanced version, try this move while standing on a BOSU.

Learn the other variation.

Know Your A, B, Cs: Vitamin B (How Many Are There?)

FitSugar — Mon, 26 Mar 2007 03:00:00 -0700

There are eight B Vitamins to be exact, and they help maintain healthy skin and muscle tone, enhance your immune and nervous system functions, and promote cell growth and division.

They are water-soluble vitamins which means that your body can't store them. They need to be replenished daily because whatever the body doesn't use, gets flushed out in your urine.

The eight B vitamins are B1, B2, B3, B5, B6, B7, B9, and B12 - and they all have other names that you're probably more familiar with.

Most people get these vitamins in the food they eat. If you have food restrictions, whether you don't eat meat, dairy products, eggs, or whole grains for whatever reason, you may need to take supplements. When a supplement has all 8 of these B vitamins, it's referred to as vitamin B complex. If you buy separate B vitamins, then they are referred to by their specific name (B1, B12, etc.)

Allow me to explain each one...

Vitamin	Benefits	Food Sources	RDA for women 19+
Vitamin B1 (Thiamine)	Helps the body convert carbohydrates and fat into energy; essential for normal growth and development; helps to maintain proper functioning of the heart and the nervous and digestive systems	Green peas, spinach, liver, beef, pork, navy beans, pinto beans, soybeans, nuts, bananas, whole grain and enriched cereals, and breads	1.4 mg/day
Vitamin B2 (Riboflavin)	Required by the body for the metabolism of fats, carbohydrates, and proteins; helps with cellular processes	Asparagus, okra, chard, almonds, leafy greens, cottage cheese, milk, yogurt, meat, eggs, and fish	1.2 mg/day

Want to see the rest? Then read more

Vitamin B3 (Niacin)	Necessary for energy metabolism in cells; DNA repair; produces several sex and stress-related hormones that are produced by the adrenal gland; helps remove toxins and chemicals from the body	Chicken, beef, tuna, salmon, milk, eggs, broccoli, tomatoes, carrots, dates, sweet potatoes, asparagus, avocados, nuts, whole grains, beans, mushrooms, nutritional yeast	14 mg/day
Vitamin B5 (Pantothenic acid)	Required to sustain life; is critical in the metabolism of fats, carbohydrates, and proteins	Whole grain cereals, beans, eggs, meat, some energy drinks	5 mg/day
Vitamin B6 (Pyridoxine and Pyridoxamine)	Help enzymes do their job in the body; helps the nervous and immune systems function properly; necessary for overall good health	Nuts, liver, chicken, fish, green beans, salad greens, wheat germ, nutritional yeast, sea vegetables, and bananas	1.3 mg/day
Vitamin B7 (Biotin or Vitamin H)	Used in cell growth; the production of fatty acid; metabolism of fat; plays a role in the Krebs Cycle in which energy is released from food; helps with the transfer of carbon dioxide; helps maintain a steady blood sugar level; found in many cosmetic products to help with your skin and hair	Beans, nutritional yeast, cauliflower, chocolate, egg yolks, fish, liver, meat, molasses, dairy products, nuts, oatmeal, oysters, peanut butter, bananas, soy products, mushrooms, wheat germ, and whole grains	300 mcg/day
Vitamin B9 (Folic acid)	Helps the body make healthy new cells; taken before and during pregnancy can help prevent major birth defects of the baby's brain and spine	Leafy greens such as spinach, dried beans and peas, sunflower seeds, oranges, asparagus, broccoli, liver, enriched cereal	400 mcg/day
Vitamin B12 (Cobalamin)	Necessary for the synthesis of red blood cells, the maintenance of the nervous system, and the growth and development of children	Animal products such as meat, eggs, dairy products, nutritional yeast, and fortified cereals	6 mcg/day

Know Your A, B, Cs: Vitamin A

FitSugar — Thu, 15 Mar 2007 12:30:00 -0700

Vitamin A - What doesn't it do? It helps with your vision, bone growth, cell growth and repair, and cell division. It helps regulate the immune system, and makes white blood cells, which help to fight off infections. Vitamin A also helps the skin and mucous membranes function as a barrier to bacteria and viruses. It also speeds up healing when you get cut, and prevents your skin from aging.

It's a good thing that vitamin A is found in so many of our foods, so you usually get enough in your diet. Colorful fruits and veggies are great sources of this vitamin. The RDA (recommended daily allowance) for women for vitamin A is 700-750 micrograms.

Are you getting enough? To find out read more

Food	Serving size	% of RDA for women
sweet potato	1/2 cup	200%
carrot	1 medium	145%
kale	1/2 cup	34%
mango	1/2 medium	28%
raw spinach	1 cup	26%
papaya	1/2 medium	21%
red bell pepper	1/2 medium	20%
canteloupe	1/2 cup	18%
large egg	1	13%
romaine lettuce	1 cup	10%
raw tomato	1 medium	5%
green bell pepper	1/2 medium	2%
orange	1 medium	2%

Well, as you can see, it's pretty easy to get your RDA of vitamin A. If you eat a salad, a carrot, or baked sweet potato, you're good to go.

Cirrhosis

FitSugar — Wed, 08 Oct 2008 17:35:33 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Cirrhosis is a condition that causes scarring of the liver as a result of chronic liver disease. Scarring blocks blood and bile flow through the liver and keeps it from working properly.

As the largest internal organ in the body, the liver performs many vital tasks. For example, it gets rid of or neutralizes toxins (such as poisons, germs, and bacteria) in the blood and controls infection. The liver also produces proteins that regulate blood clotting and bile that helps your body absorb fats and fat-soluble vitamins.

Cirrhosis is irreversible, but it progresses slowly, so early treatment can help prevent more damage. As liver function worsens, you may experience fatigue, weight loss, swelling in your legs and abdomen, and jaundice. If the disease is severe enough, it can be fatal.

The most common causes of cirrhosis in the United States are excessive use of alcohol and chronic infection with the hepatitis C virus.

Signs and Symptoms

Symptoms of cirrhosis can range from an absence of symptoms to outright liver failure.

The most common symptoms include:

Fatigue and weakness
Loss of appetite, weight loss, and nausea
Small, red spider-like blood vessels under the skin
Yellowing of the skin and eyes (jaundice)
Redness of the palms of the hands (palmar erythema)
Swelling of the belly caused by fluid retention (ascites)
Swelling of the legs, feet, and back caused by fluid buildup (edema)
Whole body itching (called pruritus)
Mental confusion (called hepatic encephalopathy), caused by a buildup in the blood of harmful toxins
Vomiting blood (from enlarged veins in the esophagus due to portal hypertension; see Complications section).

Causes

The most common cause of liver disease in the United States is alcohol abuse.

Drinking excessive amounts of alcohol on a regular basis almost always causes liver damage, although not necessarily cirrhosis. Consuming 32 - 48 oz. of beer, 4 - 8 oz. of liquor, or 16 - 32 oz. of wine every day for 10 - 15 years or longer increases your chances significantly of developing cirrhosis. How much alcohol you drink, how often, and for how many years are more important factors what kind of alcohol you drink.

Other causes of cirrhosis include:

Chronic hepatitis B and hepatitis C
Inherited diseases -- such as cystic fibrosis
Autoimmune inflammation of the liver (the body's own immune system attacks the liver)
Blocked bile ducts
Nonalcoholic fatty liver disease (where fat deposits build up in the liver and cause scar tissue to form)
Metabolic disorders of iron and copper (hemochromatosis and Wilson's disease respectively) each of which can deposit in the liver
Medications or exposure to toxic substances.

Risk Factors

Related to alcohol:

Women can develop liver disease even though they may drink less than men.
Obesity may increase your chances of developing alcoholic liver disease because of fatty deposits in the liver.

Other factors:

Inherited diseases, such as hemochromatosis and Wilson's disease
Certain medical conditions
Chronic hepatitis B or C

Diagnosis

Your doctor will take a detailed history to try to determine the cause of your liver disease and to see if your symptoms might be related to something else. Then, the doctor will examine you closely for signs of liver disease, including yellowing (jaundice) of your eyes and skin, red spider-like blood vessels just under the surface of your skin, and redness of your palms.

Your doctor will press on your abdomen to feel the size of your liver. In the early stages of liver disease, the liver may be enlarged and firm, but it shrinks as scar tissue forms.

Your doctor may order other tests, such as blood tests to look for certain liver enzymes, a bilirubin test, an ultrasound, CT scan, or MRI, or a liver biopsy.

Prevention

Drink only in moderation.
Take precautions to avoid contracting hepatitis B and C (such as being careful if your occupation exposes you to blood or blood products, practicing safe sex, getting a hepatitis B vaccine).
See your doctor regularly if you have chronic hepatitis.

Treatment

Cirrhosis is irreversible, but you can slow down the progression of the disease. Treatment depends on the underlying cause. For example, abstaining from alcohol, or taking interferon or other medications to build up your immune system if you have chronic viral hepatitis. Your doctor will also treat complications, such as giving you blood pressure medications to control portal hypertension or drugs to stop bleeding veins. In certain cases liver transplant will be necessary.

Lifestyle

If you have cirrhosis from any cause, it is vital to abstain from drinking alcohol to prevent further damage to the liver. If your cirrhosis is caused by alcoholism, your doctor may suggest Alcoholics Anonymous as a good place to start your rehabilitation and maintain your abstinence.

Medications that may cause liver damage must also be stopped. For example, acetaminophen (Tylenol) can cause liver damage if taken in large quantities or by people who drink alcohol regularly. Nonsteroidal anti-inflammatory drugs can also damage the liver, as can some herbs and supplements. If you have liver disease, do not take any over-the-counter medication, herbs, or supplements without first checking with your doctor.

Making changes in your diet, such as lowering salt intake, may be necessary to treat complications of cirrhosis.

Medications

Medications can treat complications such as bleeding from veins, infections in fluid accumulated in the abdomen, and damage to the brain (encephalopathy) caused by toxins circulating in the blood.

Blood pressure medications (beta-blockers) -- to help lower portal hypertension, an increase in blood pressure in the portal vein, which brings blood to the liver from the intestine. Beta-blockers include propranolol (Inderal) and nadolol (Coregard).
Sandostatin -- may be given to stop bleeding vessels in the esophagus or stomach by causing blood vessels to narrow.
Diuretics (water pills) -- to help reduce the amount of fluid in your abdomen or legs. Diuretics include spironolactone (Aldactone) and furosemide (Lasix).
Lactulose -- given for hepatic encephalopathy, brain and nervous system damage caused by a build up of ammonia in the blood. A damaged liver may not be able to cleanse the blood of ammonia, and lactulose, a synthetic sugar, can help stop your intestines from creating ammonia.

Surgery and Other Procedures

You may need a liver biopsy to determine the cause of cirrhosis and to assess the extent of liver damage. Generally this procedure involves inserting a needle through the abdominal wall to the liver to obtain tissue samples.

Surgery may be required to stop and prevent certain complications of cirrhosis:

Endoscopic procedures to stop bleeding from blood vessels in the esophagus
Placing a shunt to reroute blood from the liver, to lower portal hypertension
Draining fluid from the abdomen (called paracentesis)
Liver transplant

Nutrition and Dietary Supplements

Malnutrition is often a problem for people with cirrhosis. One of the liver’s important functions is to help convert food into stored energy, as well as to rid the body of toxins. For these reasons, eating a healthy diet is an important part of treatment for cirrhosis. You should be eating a well-balanced diet with plenty of fruits, vegetables, and whole grains. Your doctor may also talk with you about proper protein balance, and limiting your fluid and salt intake.

Dietary Restrictions

Protein

High-quality dietary protein may be particularly important for you if you have buildup of fluid in the abdomen or swelling of the feet, legs, or back. Protein also helps to repair muscle mass. But too much protein can raise ammonia levels and trigger hepatic encephalopathy (see Complications). In general, your doctor needs to determine how much protein is right for you. Your doctor may recommend eating vegetable protein (such as soy) instead of animal protein.

Sodium (salt)

If you have fluid retention, you may be asked to lower the amount of salt you consume, since salt encourages the body to retain water. Remember that lowering your salt intake will involve more than passing up the salt shaker; the foods highest in salt are processed and prepared foods. Examples of such foods are canned meats, soups, and vegetables, crackers, and cold cuts. Eat good amounts of fresh foods because they contain very little sodium. Instead of adding salt to your food, try lemon juice or black pepper to add taste.

Shellfish

Avoid raw shellfish, which may carry a bacteria called Vibrio vulnificus that can be dangerous to people with cirrhosis. If you are not sure how well shellfish is cooked, do not eat it.

Dietary Supplements

It is very important that you talk to your doctor before taking any supplement if you have liver disease, including the following:

Antioxidants -- There is some preliminary evidence that antioxidants, like vitamin E and selenium, might help in treating primary biliary cirrhosis, a condition in which the bile ducts of the liver are slowly destroyed. However, a later double-blind, placebo controlled study found no benefit from a combination of vitamins A, C, E, plus selenium, methionine, and co-enzyme Q10. While there is no evidence that taking these supplements will help, you can boost the amount of antioxidants you get by eating lots of fresh fruits, vegetables, and whole grains.
Betaine (20 g per day in two doses) -- Betaine is a nutrient that reduces homocysteine levels in the body, which are associated with heart disease and are higher in people with liver disease. Preliminary studies have suggested that betaine might be helpful in treating nonalcoholic fatty liver disease and alcohol-induced cirrhosis. In one preliminary study, 10 people with fatty liver disease took betaine for up to 1 year and had improvement in liver function tests and a reduced amount of fat and other changes in the liver itself. More research is needed.
S-adenosylmethionine (SAMe, 1,200 - 1,600 mg per day) -- SAMe, a naturally occurring antioxidant that is involved in many chemical processes in the body, is best known for its antidepressant effects. But it is also involved in the processes of the liver. People with liver disease have low levels of SAMe, and this may in turn lead to low levels to glutathione. Several studies seem to indicate that taking SAMe may reduce symptoms of liver disease and normalize bilirubin and liver enzyme levels. However, most of the studies have been small and some have used intravenous (IV) SAMe. More studies are needed to determine what benefits SAMe might provide. SAMe interacts with a number of medications, including prescription antidepressants.
Branched chain amino acids (BCAAs) -- BCAAs, which are involved in synthesizing protein in the body, have shown promise is treating hepatic encephalopathy, a brain disorder caused by a buildup of toxins in the blood. Some studies suggest that taking BCAAs can help people with chronic hepatic encephalopathy improve liver function tests and motor ability. However, not all studies show any benefit.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, like medications, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. People with liver disease must be particularly careful because the liver processes almost everything you ingest. For these reasons, you should take herbs with extreme care and only under the supervision of your doctor.

Bupleurum (Bupleurum chinese) -- The Chinese herb bupleurum has anti-inflammatory properties and has been used historically to treat liver disorders. In one study, a formulation that contained bupleurum appeared to reduce the risk of liver cancer in people with cirrhosis.
Licorice root (Glycyrrhiza glabra) -- Licorice root has been used in both Eastern and Western medicine to treat a variety of illnesses, including liver disease. Some preliminary data from Japanese researchers suggests that taking glycyrrhizin (an active component of licorice root) along with cysteine and glycerine might help reduce the risk of cirrhosis if you have hepatitis C. However, the formula was delivered intravenously (IV). It is not known whether taking these substances by mouth would have any effect. More studies are needed. People with high blood pressure or those who take steroids, digoxin (Lanoxin), diuretics (water pills), or anticoagulants (blood thinners such as warfarin (Coumadin) should not take licorice. Pregnant women should avoid licorice.
Milk thistle (Silybum marianum, 420 mg per day standardized to 70 - 80% silymarin for cirrhosis; 240 mg two times per day of silibinin for chronic hepatitis) -- Milk thistle has been used since Greco-Roman times to treat liver problems. Several scientific studies lend support to this traditional use. They suggest that a substance in milk thistle (silymarin) can protect the liver from damage caused by viruses, toxins, alcohol, and certain drugs such as acetaminophen. However, the evidence is stronger for some conditions than others:
- Studies are mixed as to whether milk thistle improves liver function tests or the death rate for people with alcohol-induced cirrhosis.
- Studies are also mixed as to whether milk thistle improves liver function tests or quality of life for people with chronic active hepatitis B or C.
- Milk thistle may reduce liver damage caused by mushroom poisoning (due to Amanita phalloides, or death’s cap mushroom)
- Milk thistle may help protect the liver against damage from exposure to industrial toxins.

In a comprehensive review of studies on milk thistle by the U.S. Agency for Healthcare Research and Quality (AHRQ), milk thistle improved liver function in people with mild liver disease but was less effective for those with severe liver disease such as cirrhosis.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider remedies, based on their knowledge and experience, for reducing the physical addiction to alcohol and for helping to treat hepatitis. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Remedies that may be recommended for alcoholism include:

Nux vomica
Staphysagria
Belladonna
Stramonium
Chelidonium
Zincum
Carduus marianus

Remedies that may be recommended for hepatitis include:

Aconitum
Belladonna
Chelidonium
China
Lycopodium
Mercurius
Phosphorus

Other Considerations

Your doctor will use caution when prescribing medications if you have cirrhosis because many medications cause complications in someone with a weakened liver.

Similarly, certain herbs and supplements are known to cause harm to the liver or cause complications that affect those with liver disease. A short list is below; talk to your doctor before taking any herb or supplement if you have liver disease.

Kava kava (an herb used for anxiety and tension) can be toxic to the liver and cause severe hepatitis and even liver failure in high doses.
Vitamin A in high doses can be toxic to the liver.
Mistletoe (Phoradendron leucarpum)
Germander (Teucrium chamaedrys)
European barberry (Berberis vulgaris)

Pregnancy

Pregnant or breastfeeding women should not use milk thistle or licorice.

Prognosis and Complications

Complications from cirrhosis include:

Portal hypertension (buildup of pressure in the large vein supplying blood to the liver)
Bleeding esophageal varices (enlarged veins at the lower end of the esophagus that have a tendency to bleed; caused by portal hypertension)
Hepatic encephalopathy (brain disorder caused by buildup of toxins), which causes forgetfulness and mental confusion; may lead to coma
Ascites (abdominal fluid retention) and bacterial peritonitis (infection of the fluid)
Sepsis (presence of harmful organisms or their toxins in the blood or tissues)
Liver cancer
Kidney failure
Osteoporosis
Insulin resistance

Cirrhosis can be serious and life-threatening, particularly if you continue to drink alcohol. The good news is that with proper diet, medical management, and avoidance of alcohol, you can drastically slow down the rate of progression of liver damage.

Supporting Research

Abittan CS, Lieber CS. Alcoholic liver disease. Curr Treat Options Gastroenterol. 1999;2(1):72-80.

Agency for Healthcare Research and Quality. Milk thistle: effects on liver disease and cirrhosis and clinical adverse effects. Summary, evidence report/technology assessment: number 21, September 2000. American Liver Foundation. Cirrhosis. Accessed on September 14, 2007.

Angulo P, Lindor KD. Treatment of nonalcoholic fatty liver: present and emerging therapies. Semin Liver Dis. 2001;21(1):81-88.

Barak AJ, Beckenhauer HC, Tuma DJ. Betaine, ethanol, and the liver: a review. Alcohol. 1996; 13(4): 395-398.

Cave M, Deaciuc I, Mendez C, Song Z, Joshi-Barve S, Barve S, McClain C. Nonalcoholic fatty liver disease: predisposing factors and the role of nutrition. J Nutr Biochem. 2007 Mar;18(3):184-95. Review.

Chitturi S, Farrell GC. Herbal hepatotoxicity: an expanding but poorly defined problem. J Gastroenterol Hepatol. 2000;15(10):1093-1099.

Day CP. Who gets alcoholic liver disease: nature or nurture? J R Coll Physicians Lond. 2000;34(6):557-562.

Ferenci P, Dragosics B, Dittrich H, et al. Randomized controlled trial of silymarin treatment in patients with cirrhosis of the liver. J Hepatol. 1989;9:105-113.

Fiore C, Eisenhut M, Krausse R, Ragazzi E, Pellati D, Armanini D, Bielenberg J. Antiviral effects of Glycyrrhiza species. Phytother Res. 2007 Sep 20; [Epub ahead of print]

Fukushima H, Miwa Y, Shiraki M, Gomi I, Toda K, Kuriyama S, et al. Oral branched-chain amino acid supplementation improves the oxidized/reduced albumin ratio in patients with liver cirrhosis. Hepatol Res. 2007 Sep;37(9):765-70.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:1138-1139.

Imai K, Nakachi K. Cross sectional study of effects of drinking green tea on cardiovascular and liver diseases. BMJ. 1995;310(6981):693-695.

Kalaitzakis E, Bjornsson E. Renal function and cognitive impairment in patients with liver cirrhosis. Scand J Gastroenterol. 2007 Apr 30:1-7.

Langmead L, Rampton DS. Review article: herbal treatment in gastrointestinal and liver disease -- benefits and dangers. [Review]. Aliment Pharmacol Ther. 2001;15(9):1239-1252.

Lieber CS. Liver disease by alcohol and hepatitis C: early detection and new insights in pathogenesis lead to improved treatment. Am J Addict. 2001;10 Suppl:29-50.

Lirussi F, Azzalini L, Orando S, Orlando R, Angelico F. Antioxidant supplements for non-alcoholic fatty liver disease and/or steatohepatitis. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004996. Review.

Liu CT, Chuang PT, Wu CY, Weng YM, Chen W, Tseng CY. Antioxidative and in vitro hepatoprotective activity of Bupleurum kaoi leaf infusion. Phytother Res. 2006 Nov;20(11):1003-8.

Loguercio C, Nardi G, Argenzio F, et al. Effect of S-adenosyl-L-methionine administration on red blood cell cysteine and glutathione levels in alcoholic patients with and without liver disease. Alcohol Alcohol. 1994;29(5):597-604.

Luper S. A review of plants used in the treatment of liver disease: part two. [Review]. Altern Med Rev. 1999;4(3):178-188.

Mato JM, Camara J, Fernandez de Paz J. S-adenosylmethionine in alcoholic liver cirrhosis: a randomized, placebo-controlled, double-blind, multicenter clinical trial. J Hepatol. 1999;30:1081-1089.

Moriarty KJ, Platt H, Crompton S, Darling W, Blakemore M, Hutchinson S, et al. Collaborative care for alcohol-related liver disease. Clin Med. 2007 Apr;7(2):125-8.

Nakaya Y, Okita K, Suzuki K, Moriwaki H, Kato A, Miwa Y, et al; Hepatic Nutritional Therapy (HNT) Study Group. BCAA-enriched snack improves nutritional state of cirrhosis. Nutrition. 2007 Feb;23(2):113-20.

National Digestive Diseases Information Clearinghouse. Cirrhosis of the liver. 2003; NIH Publication No. 04-1134. Accessed on September 14, 2007.

Seeff LB, Lindsay KL, Bacon BR, Kresina TF, Hoofnagle JH. Complementary and alternative medicine in chronic liver disease. Hepatology. 2001 Sep;34(3):595-603.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995:314-317.

Urata Y, Okita K, Korenaga K, Uchida K, Yamasaki T, Sakaida I. The effect of supplementation with branched-chain amino acids in patients with liver cirrhosis. Hepatol Res. 2007 Jul;37(7):510-6.

Verma S, Thuluvath PJ. Complementary and alternative medicine in hepatology: review of the evidence of efficacy. Clin Gastroenterol Hepatol. 2007 Apr;5(4):408-16. Review.

Vintro AQ, Krasnoff JB, Painter P. roles of nutrition and physical activity in musculoskeletal complications before and after liver transplantation. AACN Clin Issues. 2002;13(2):333-347.

Wang R, Kong J, Wang D, Lien LL, Lien EJ. A survey of Chinese herbal ingredients with liver protection activities. Chin Med. 2007 May 10;2:5.

Yen MH, Weng TC, Liu SY, Chai CY, Lin CC. The hepatoprotective effect of Bupleurum kaoi, an endemic plant to Taiwan, against dimethylnitrosamine-induced hepatic fibrosis in rats. Biol Pharm Bull. 2005 Mar;28(3):442-8.

Review Date:
9/30/2007
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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

Insomnia

FitSugar — Wed, 08 Oct 2008 17:34:55 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Insomnia is the inability to sleep when sleep should normally occur. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than 8 hours of sleep a day, but only 35% of American adults consistently get this amount of rest.

People with insomnia tend to experience one or more of the following sleep disturbances:

Difficulty falling asleep at night
Waking too early in the morning
Waking frequently throughout the night

Insomnia may stem from a disruption of the body's circadian rhythm, an internal clock that governs the timing of hormone production, sleep, body temperature, and other functions. While occasional restless nights are normal, prolonged insomnia can interfere with daytime function, concentration, and memory. Insomnia increases the risk of substance abuse, motor vehicle accidents, headaches, and depression. Recent surveys indicate that 50% of people suffer from sleep difficulties, and 20 - 36% of them struggle with such difficulties for at least 1 year. Other studies show that one person out of three in the United States has insomnia, but only 20% tell their health care providers about it.

Signs and Symptoms

Not feeling refreshed after sleep
Inability to sleep despite being tired
Daytime drowsiness, fatigue, irritability, difficulty concentrating, and impaired ability to perform normal activities
Anxiety as bedtime approaches

Causes

No known physical or mental condition causes primary insomnia. Everyday anxiety and stress, coffee, and alcohol are the most common culprits.

An underlying medical or psychological condition, such as depression,, often causes secondary insomnia.

About 50% of insomnia cases have no identifiable cause.

Some conditions or situations that commonly lead to insomnia include:

Substance abuse -- consuming excessive amounts of caffeine, alcohol, recreational drugs, or certain prescription medications such as stimulants. Smoking can cause restlessness and quitting smoking may also cause temporary insomnia.
Disruption of circadian rhythms -- shift work, travel across time zones, or vision loss. Circadian rhythms are regulated, in part, by release of a hormone called melatonin from the brain. As individuals age, less melatonin is available for use by the body.
Menopause -- between 30 - 40% of menopausal women experience insomnia. This may be due to hot flashes, night sweats, anxiety, or fluctuations in hormone levels.
Hormonal changes during menstrual cycle -- insomnia may occur during menstruation. Sleep improves mid-cycle with ovulation.
Advanced age -- biological changes associated with aging, underlying medical conditions, and side effects from medications all contribute to insomnia.
Medical conditions -- gastroesophageal reflux (return of stomach contents into the esophagus), fibromyalgia, other chronic pain syndromes, heart disease, arthritis, attention deficit hyperactivity disorder, and obstructive sleep apnea (difficulty breathing during sleep).
Psychiatric and neurologic conditions -- anxiety, depression, manic-depressive disorder, dementia, Parkinson's disease, restless legs syndrome, post-traumatic stress disorder.
Certain medications -- decongestants (such as pseudoephedrine or Sudafed), bronchodilators (such as albuterol or Proventil inhaler), and beta-blockers (such as metoprolol or Lopressor).
Excessive computer work.
Partners who snore.

Risk Factors

The following factors may increase an individual's risk for insomnia:

Age -- the elderly are more prone to insomnia
Stressful or traumatic event
Night shift or changing work schedule
Travel across time zones
Substance abuse
Asthma -- bronchodilators occasionally cause insomnia
Excessive computer work

Diagnosis

Clinical history (including all current medication and recreational drug use) and physical exam are usually sufficient to make the diagnosis. Polysomnography, an overnight sleep study, can be helpful to rule out other types of sleep disorders (such as breathing-related sleeping disorder).

Preventive Care

The following lifestyle changes can help prevent insomnia:

Exercising regularly -- best when done before dinner. Exercise should not be done too close to bedtime because it can cause restlessness.
Avoiding caffeine (especially after noon) and nicotine.
Getting regular exposure to late afternoon sun. This helps to stimulate release of melatonin to regulate circadian rhythm.
Practicing stress reduction techniques, such as yoga, meditation, or deep relaxation.
Early treatment of insomnia may also help prevent psychiatric disorders, such as depression.

Treatment

The preferred treatments for people with chronic insomnia are lifestyle changes and behavioral approaches that establish healthy sleeping habits. This is called improving sleep hygiene.

Mind-body therapies -- such as stimulus control therapy, bright-light therapy, and cognitive-behavioral therapy -- are particularly helpful.

Acupuncture and acupressure have a long tradition of treating insomnia successfully, particularly in the elderly. Vitamins, along with homeopathic and herbal remedies, may also improve symptoms in some individuals.

Lifestyle

Healthy sleep habits are essential for treating insomnia. The following strategies (in addition to the steps mentioned in the "Preventive Care" section) may help treat the condition:

Maintain a consistent sleeping and waking time.
Establish the bedroom as a place for sleep and sexual activity only, not for reading, watching television, or working.
Avoid naps, especially in the evening.
Take a hot bath about 2 hours before bedtime.
Keep the bedroom cool, well-ventilated, quiet, and dark.
Avoid looking at the clock -- this promotes anxiety and obsession about time.
Avoid fluids just before bedtime.
Avoid exercising before bedtime.
Avoid television just before bedtime.
Eat a carbohydrate snack, such as cereal or crackers, just before bedtime.
Move to another room with dim lighting if sleep does not occur within 15 - 20 minutes in bed.

Medications

If changes in sleep hygiene do not help, prescription medications (including benzodiazepines) may be appropriate. Benzodiazepines include temazepam (Restoril), flurazepam (Dalmane), estazolam (ProSom), and triazolam (Halcion). Benzodiazepines may cause psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat.

Another class of sedative hypnotic medications includes the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and fewer adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta).

Ramelteon (Rozerem) belongs to a new class of drugs called melatonin agonists. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Side-effects may include daytime sleepiness, dizziness, and fatigue.

Over-the-counter (OTC) antihistamines may be used short-term for insomnia. Diphenhydramine (Benadryl) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl, Nytol, Sominex) or in combination with other OTC items, such as acetaminophen (Tylenol PM). Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation.

Generally, OTC and prescription medications help promote sleep, but they are not recommended for insomnia that last for more than 4 weeks. Long-term use of some medications may cause addiction, particularly if the patient has a history of substance abuse.

Nutrition and Dietary Supplements

Following these nutritional tips may help reduce symptoms:

Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
Eat more antioxidant rich foods (such as green leafy vegetables) and fruits (such as blueberries, pomegranates, and cherries).
Avoid refined foods, such as white breads, pastas, and sugar.
Eat fewer red meats and more lean meats, cold-water fish, or beans for protein.
Use healthy cooking oils, such as olive oil or vegetable oil.
Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise 30 minutes daily, 5 days a week. Exercising in the evening after dinner may lead to insomnia.
Foods rich in carbohydrates and low in protein and fat may boost the production of serotonin and melatonin, brain chemicals that are associated with sleep. A carbohydrate snack of granola, non-sweetened cereals, or crackers with milk before bed may help.

The following dietary supplements may also be helpful in promoting sleep:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tbsp. oil one to three times daily, to help decrease inflammation and help with mental balance.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization and sleep improvement.
L-theanine, 200 mg one to three times daily, for nervous system support.
Melatonin, 1 - 6 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

L-tryptophan and 5-hydroxytryptophan (5-HTP)

Medical research indicates that taking 1 g L-tryptophan before bedtime can induce sleepiness and delay wake times. Researchers think L-tryptophan brings on sleep by raising levels of serotonin, a body chemical that promotes relaxation. However, consumers should take this supplement with caution as it may adversely interact with certain antidepressants [including selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs)] and cause serious negative side effects. Reports of eosinophilia myalgia syndrome (EMS: an autoimmune disorder characterized by fatigue, fever, muscle pain and tenderness, cramps, weakness, hardened skin, and burning, tingling sensations in the extremities) from contaminated L-tryptophan supplements surfaced in 1989, and isolated incidents of EMS continue to be reported.

Studies also suggest that 5-hydroxytryptophan (5-HTP), made from tryptophan in the body or available in supplement form, may be useful in treating insomnia associated with depression. Like tryptophan, reports of EMS have been associated with use of 5-hydroxytryptophan. Talk to a health care professional before taking 5-HTP supplements if you are on antidepressant medications. Drug interactions may occur.

Melatonin

Melatonin supplements help induce sleep, particularly in people who have disrupted circadian rhythms (such as from jet lag or shift work), or those with low levels of melatonin (such as some people with schizophrenia). In fact, a recent review of scientific studies found that melatonin supplements help prevent jet lag, particularly in people who cross five or more time zones. A few clinical studies suggest that melatonin is significantly more effective than placebo, or dummy pill, in decreasing the amount of time required to fall asleep, increasing the number of sleeping hours, and boosting daytime alertness. Although research suggests that melatonin may be modestly effective for treating certain types of insomnia, few studies have investigated whether melatonin supplements are safe and effective for long term use. More research is needed in this area.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink two to four cups per day. You may use tinctures alone or in combination as noted:

Kava kava (Piper methysticum) standardized extract, 100 - 250 mg one to three times daily, as needed for relaxation. Kava should not be used in those with liver problems or those drinking alcohol in excessive quantities.
Rhodiola (Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and antistress activity.
Valerian (Valeriana sp.) standardized extract, 200 - 400 mg at bedtime, for sleep.
Chamomile (Anthemis nobilis), standardized extract, 400 - 1,600 mg daily, for relaxation. A tea may be prepared from chamomile flowers. Chamomile is not recommended for individuals allergic to flowers in the daisy family.

Homeopathy

A few studies have examined the effectiveness of specific homeopathic remedies. However, a professional homeopath may recommend one or more of the following treatments for insomnia, based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Aconitum -- for insomnia that occurs as a result of illness, fever, or vivid, frightening dreams; commonly used for children.
Argentum nitricum -- for impulsive children who are restless and agitated before bedtime and cannot fall asleep if the room is too warm.
Arsenicum album -- for insomnia that occurs after midnight due to anxiety or fear. This remedy is most appropriate for demanding individuals who are often restless, thirsty, and chilly.
Chamomilla -- for insomnia caused by irritability or physical pains; sleep may be disturbed by twitching and moaning. This remedy is appropriate for infants who have difficulty sleeping because they are teething or colicky, and older children may demand things, then refuse them when they are offered.
Coffea -- for insomnia due to excitable news or sudden emotions. This remedy is most appropriate for individuals who generally have difficulty falling asleep and tend to be light sleepers. Often used to counteract the effects of caffeine, including in infants exposed to caffeine through breast-feeding.
Ignatia -- for insomnia caused by grief or recent loss. This remedy is most appropriate for individuals who yawn frequently or sigh while awake.
Kali phosphoricum -- for night terrors associated with insomnia. This remedy is most appropriate for individuals who are easily startled and restless, often with fidgety feet. Anxiety is often caused by both nightmares and events in the individual's life.
Nux vomica -- for insomnia caused by anxiety, anger, irritability, or use of caffeine, alcohol, or drugs. This remedy is most appropriate for individuals who wake up early in the morning, or for children who often have dreams of school or fights and may be awakened by slight disturbances. Nux vomica may also be used to treat insomnia that occurs as a side effect of medications.
Passiflora -- for the elderly and young children with often overactive minds.
Pulsatilla -- for women and children who are particularly emotional and do not like sleeping alone. Also used when sleeping in a warm room tends to worsen insomnia or when the individual may cry due to the inability to fall asleep.
Rhus toxicodendron -- for restlessness and insomnia caused by pains that occur when the individual is lying down.

Acupuncture

Some reports suggest that certain acupuncture procedures have a nearly 90% success rate for the treatment of insomnia. Through a complex series of signals to the brain, acupuncture increases the amount of certain substances in the brain, such as serotonin, which promote relaxation and sleep.

Several clinical studies have found that auricular acupuncture is effective in reducing symptoms of insomnia, such as difficultly in falling asleep and remaining asleep. Auricular acupuncture uses needles placed at various points in the ear. Further studies should be performed.

Clinical studies of elderly people with sleep disturbances suggest that acupressure enhances sleep quality and decreases awakenings during the night. An acupressure practitioner works with the same points used in acupuncture, but stimulates these healing sites with finger pressure, rather than inserting fine needles. Clinical studies support the use of auricular (ear) acupressure for improving sleep quality in elderly patients and possibly in healthy adults of all ages. A small clinical study also found that acupressure may help with sleep apnea.

Chiropractic

No well-designed studies have evaluated the effect of chiropractic care on individuals with insomnia, but chiropractors report that spinal manipulation may improve symptoms of the condition in some individuals. In these cases, spinal manipulation may have a relaxing effect on the nervous system.

Massage and Aromatherapy

Massage has long been known to enhance relaxation and improve sleep patterns. While massage alone is an effective method for relaxation, studies suggest that massage with essential oils (called aromatherapy), particularly lavender (Lavandula angustifolia), may result in improved sleep quality, more stable mood, increased mental capacity, and reduced anxiety. Clinical studies have found participants who received massage with lavender felt less anxious and more positive than participants who received massage alone.

Mind-Body Medicine

A variety of behavioral techniques have proved helpful in treating insomnia. These methods, with the guidance of a sleep specialist or a sleep specialty team, are singly used to treat insomnia, but they may also be combined with other treatment methods including:

Sleep Diary. Keeping a daily/nightly record of sleep habits (including the amount of sleep, how long it takes to fall asleep, the quality of sleep, the number of awakenings throughout the night, any disruption of daytime behaviors, attempted treatments and how well they worked, mood, and stress level) can help a person understand and, consequently overcome their insomnia.
Stimulus Control Techniques. This technique involves learning to use the bedroom only for sleep and sexual activity. Individuals using this technique learn to go to bed only when tired and leave the bedroom when they’re not sleeping. They wake up at the same time every day, including weekends and vacations, regardless of the amount of sleep they had.
Sleep Restriction. This method improves sleep "efficiency" by attempting to sleep at least 85% of time spent in bed asleep. The time spent in bed is decreased each week by 15 - 20 minutes until the 85% goal is achieved. Once accomplished, the amount of time in bed is increased again on a weekly basis.
Relaxation Training Techniques. Progressive relaxation, meditation, yoga, guided imagery, hypnosis, or biofeedback can break the vicious cycle of sleeplessness by decreasing feelings of anxiety about not being asleep. Studies indicate that these therapies significantly reduce the amount of time it takes to fall asleep, increase total sleep time, and decrease the number of nightly awakenings.
Cognitive-Behavioral Therapy. This therapy is intended to re-establish healthy sleep patterns by helping an individual cope with their sleep problem. One cognitive-behavioral approach, called paradoxical intention, helps to retrain an individual's fears of sleep by doing the opposite of the behavior that causes anxiety. For example, a person with insomnia worries long before going to bed about not being able to sleep and the difficulty they will have at bedtime. Rather than preparing to go to sleep, the person prepares to stay awake. Another cognitive-behavioral technique, called thought stopping, allows a person with insomnia a certain period of time to repeatedly and continuously think about going to bed. This technique helps "wear out" the anxiety associated with going to bed, and decreases the likelihood that he they will obsess about falling asleep at other times.

Traditional Chinese Medicine

Many methods have been used historically in Traditional Chinese Medicine to treat insomnia, including herbal remedies, acupuncture, acupressure, Chinese massage (tui na), and qi gong.

Other Considerations

Pregnancy

Insomnia usually occurs in the later months of pregnancy when the mother's size and need to urinate disrupt sleep.
Women who are pregnant and nursing mothers should avoid benzodiazepines.

Warnings and Precautions

People who are taking prescription medications or over-the-counter sleeping pills should avoid alcohol.
Discontinuing prescription medications or over-the-counter sleeping pills can lead to rebound insomnia.

Prognosis and Complications

Most people who have insomnia with no underlying medical conditions recover within a few weeks. For those who develop insomnia from a traumatic event (such as those with posttraumatic stress disorder), sleep disruptions can continue indefinitely. People who become dependent on sleeping pills and prescription medication for sleep often have the most difficulty overcoming insomnia.

Supporting Research

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Review Date:
12/7/2007
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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