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Pilates 101: Finding Neutral Spine

FitSugar — Fri, 30 Jan 2009 10:00:00 -0800

The concept of neutral spine may sound simple, but this important Pilates concept can be elusive. To keep a neutral shade of spine, you maintain the natural curves of your back while doing an exercise, such as an upper abdominal curl (aka crunches). Keeping neutral means the muscles in your back are working in conjunction with your abs, and when you get your abs and back to fire together, you are working your core. Maintaining those natural curves keeps your ab work honest and makes it more difficult to cheat.

Although the concept of leaving things as they are sounds simple, when the majority of people lie on their backs, they automatically press their low spines into the floor. This, my friends, is not neutral.

To find your neutral spine:

Lie down on your back with your knees bent and your feet flat on the floor, with your heels about a foot from your bum.
Rock your pelvis up and down so you can feel the top and bottom of your sacrum, the bony back of your pelvis.
Stop rocking and feel the entire sacrum on the ground, allowing the five vertebrae in your lumbar spine to make a gentle curve away from the floor. It will not be big curve!
Your bottom rib should also be making contact with the floor.
The curve of your neck should mirror the curve of your low spine, so it pulls away from the floor as well.

To learn how to find neutral spine from the front of your body, simply read more.

You can also monitor your neutral spine from the front.

Your pubic bone and top of your pelvis (ASIS) should be on the same plane and parallel to the floor.
To get a sense if these bones are even, place the heels of your palm on the top of your pelvis and the middle fingers of both hands on your pubic bone. These bones should be on the same plane.
The apex of the curve in your lower (lumbar) spine should be even with your belly button. This is another way to feel that the curve is there but not huge!

When lying on your back with both feet off the ground, you should round your low back (super scoop) and not maintain neutral. In those positions (like the 100s in Pilates), rounding the spine protects your back!

Source

Back to Basics: Finding Neutral Spine

FitSugar — Mon, 20 Aug 2007 09:30:00 -0700

The concept of neutral spine sounds easy. You maintain the natural curves of your spine while doing an exercise – like an upper abdominal curl. Keeping neutral means the muscles in your back will be working along with your abs and when you get your abs and back to fire together you are working your core. Also, it is more difficult to recruit your leg muscles to help you cheat when you maintain neutral spine during ab work.

The concept sound simple, natural even, but when the majority of people lie down on their backs to exercise they automatically and immediately press their low spines into the floor. This, my friends, is not neutral.

So how to find neutral?

Lie down on your back with your knees bent and your feet flat on the floor, with your heels about a foot from your bum.
Rock your pelvis up and down so you can feel the top and bottom of your sacrum - the back of your pelvis.
Stop rocking and feel the entire sacrum on the ground, allowing the 5 vertebrae in your lumbar spine to make a gentle curve away from the floor. It is not a big curve!
Your bottom rib should also be making contact with the floor.
The curve of your neck should mirror the curve of your low spine, so it pulls away from the floor as well.

To learn how to find neutral spine from the front just read more

You can also approach figuring neutral spine from the front.

Your pubic bone and top of your pelvis (ASIS) should be in the same plane and parallel to the floor.
To get a sense if these bones are even, place the heels of your palm on the top of your pelvis and the middle finger, of both hands on your pubic bone. These bones should be on the same plane.
The apex of the curve in your lower (lumbar) spine, should be even with your belly button. This is another way to feel that the curve is there, but not huge!

Fit's Tip: When lying on your back with both feet off the ground, you should round your low back (super scoop) and not maintain neutral. In those positions (like the 100's in Pilates), rounding the spine protects your back!

Source

5 Things: You'll Learn In Your First Pilates Session

FitSugar — Thu, 18 Jan 2007 15:15:00 -0800

If you are curious about Pilates but want to know a little bit more about what to expect at your first class - here's a list of five concepts you will likely learn early on in your first session or group class.

Finding your deep abs, aka transverse abdominis. You work your deep abs in every Pilates exercise, so chances are you will start here. These deep muscles can be hard to isolate without squeezing your bum or tucking your pelvis.
Breathing. Every exhale is a chance to work your deep abs since they work when you force an exhale. Sounds simple but it takes a little practice. You will also learn how to inhale without tensing your shoulders.
Finding neutral spine is a key part of the Pilates repertoire. You will learn how to keep your spine in neutral alignment (keeping its natural curves) while you a) breathe and b) move.
Articulating your spine - this means moving one vertebra at a time. Basically this is the opposite of the "neutral position" and works the flexibility of your spine.
Learning the upper abdominal position - you want to be able to lift your head without straining your neck and to find the spot to optimize your upper ab work.

The Skinny On: Neutral Spine

FitSugar — Wed, 29 Nov 2006 04:00:00 -0800

We all want to have some neutral shoes and neutral pants in our wardrobes. But what about a neutral spine? If you have heard an instructor use the term neutral spine in a fitness class, but didn't have a chance to clarify its meaning - I'm here to give you the skinny on it.

Neutral spine means maintaining the natural curves of your spine. If you are lying on your back, the lowest 5 vertebrae should NOT be smashed into the ground but making a slight curve away from the floor. Your rib cage does rest on the floor. The neck mirrors your lower back and pulls away from the floor, while your skull rests heavily on the ground.

When lying on your back, a simple way to check if you are indeed in neutral is to make sure your ASIS (that's what folks commonly call their "hip bone") is in the same line as your pubic bone. Place the bottom of your palms on the ASIS and your middle fingers on your pubic bone. They should make a plane parallel to the floor. To see a spine way past neutral read more

This spine is way past neutral - the ribs are away from the ground and more than the 5 lower back vertebrae are off the floor.

Why we like it: Working in neutral spine is the best way to work your core since the back muscles are working in tandem with your abs.

Back pain and sciatica

FitSugar — Wed, 08 Oct 2008 17:35:00 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Diagnosis
Medications
Complementary and Alternati...
Exercise and Physical Thera...
Surgery
Other Treatments
Specific Treatment for Acut...
Specific Treatment for Chro...
Prognosis
Complications
Prevention
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Surgery

Kyphoplasty, a surgical technique used to treat spinal fractures, does not improve a person's back pain or quality of life, according to a review published in 2006 by a nonprofit health services research agency. Kyphoplasty should only be done if bed rest, medicines, and physical therapy do not relieve back pain.

Ultrasound

Therapeutic ultrasound uses sound waves to deliver gentle vibrations to an area of the body. Scientists in England are studying whether therapeutic ultrasound may help relieve pain and disability due to sciatica.

Acupuncture

Studies continue to show that acupuncture helps some patients with low back pain. Now, research published in the British Medical Journal online says the alternative treatment seems to be worth the price in the long run.

Stem Cells

Researchers in England have pioneered a new technique to grow new spinal tissue using stem cells. Stem cells are the building blocks of specific cells. Every cell in the human body starts (or "stems") from a stem cell. Researchers say a patient's stem cells may someday be used to grow new tissue that can replace damaged discs.

Back pain tied to brain changes

Chronic back pain appears to be linked to tiny structural changes in the brain. German researchers have found that persons with chronic back pain have more activity in the parts of the brain involved in pain processing and emotional responses. It is unclear if the brain changes came before the pain or if they occurred in response to the pain. The scientists presented their findings at the 2006 Radiological Society of North American annual meeting.

Introduction

Back pain is one of the most common reasons people visit their doctor. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 8 out of 10 people have some type of backache.

Back pain can be acute or chronic.

Acute pain develops suddenly and goes away within 6 weeks. Acute pain is the most common type of back pain.
Chronic pain can come on fast or slow, but it lasts longer than 3 months. Back pain can occur in any area of the back, but it is more common in the lower part, which supports most of the body’s weight.

The back is highly complex, and pain may result from damage or injury to any of various bones, nerves, muscles, ligaments, and other structures. Still, despite sophisticated techniques that provide detailed anatomical images of the spine and other tissues, the cause of most cases of back pain remain elusive.

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

The cervical (C) vertebrae are the seven spinal bones that support the neck.
The thoracic (T) vertebrae are the twelve spinal bones that connect to the rib cage.
The lumbar (L) vertebrae are the five lowest and largest bones of the spinal column. Most of the body's weight and stress falls on the lumbar vertebrae.

Click the icon to see an image of the spine.

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 two to four tiny, partially fused vertebrae known as the coccyx or "tail bone."

Click the icon to see an image of the sacrum.

Each vertebra is designated by using a letter and number, which allows the doctor to determine where it is in the spine.

The letter reflects the spinal region where the vertebra is located: C=cervical (neck region), T=thoracic (chest, or middle back, region), and L=lumbar (lower back).
The number signifies the vertebra's place within that spinal region. The numbers start with 1 at the top of a region and count up as the vertebrae descend within the region. For example, C4 is the fourth bone down in the cervical region and T8 is the eighth thoracic vertebrae.

The Disks. Vertebrae in the spinal column are separated from each other by small cushions of cartilage known as intervertebral disks. The disks have no blood supply of their own. They need to rely on nearby blood vessels to keep them nourished.

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

Each disk is 80% water and contains two structures.

Inside each disk is a jelly-like substance called the nucleus pulposus.
The nucleus pulposus is surrounded by a tough, fibrous ring called the annulus.

Click the icon to see an image of the nucleus pulposus.

Processes. Each vertebra in the spine has a number of bony projections called 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.

Click the icon to see an image of the vertebrae and spinal cord.

Spinal Cord. The spinal cord is the central trunk of nerves that connects the brain with the rest of the body. Each nerve root passes from the spinal column to other parts of the body through small openings bounded on one side by the disk and the other by the facets. When the spinal cord reaches the lumbar region, it splits into four bundled strands of nerve roots called the cauda equina (meaning horsetail in Latin).

Click the icon to see an image of the cauda equina.

Causes

In about 85% of back pain cases, the origin of the pain is unknown, and imaging studies usually fail to determine the cause. Disk herniation and disk degeneration due to aging are the most common causes of low back pain. Other problems can also cause this pain, however.

Over the years, the disk can wear away (degenerate), causing inflammation and irritation. This age-related condition is a major source of chronic low back pain.

A herniated disk, sometimes, but incorrectly, called a slipped disk, is widely held to be the most common cause of severe back pain and sciatica. A disk in the lumbar area becomes herniated when it ruptures or thins out and degenerates to the point that the gel within the disk (nucleus pulposus) pushes outward. The damaged disk can take many forms.

A bulge -- The gel has been pushed out slightly from the disk and is evenly distributed around the circumference.
Protrusion -- The gel has pushed out slightly and asymmetrically in different places.
Extrusion -- The gel balloons extensively into the area outside the vertebrae or breaks off from the disk.

There is some debate, however, about how pain develops from a herniated disk and how frequently it causes low back pain. Many people have disks that bulge or protrude and do not suffer back pain. Extrusion (which is less common than the other two conditions) is highly associated with back pain, since the gel is likely to extend out far enough to press against the nerve root, most often the sciatic nerve. Extrusion is very uncommon, however, while sciatic and low-back pain are very common. But there may be other causes of low back pain

Ordinarily, at the time of any injury, the immune system triggers key factors that are designed to promote healing. Evidence is now pointing to an abnormal and persistent immune response in the cells of the nucleus pulposus that may be responsible for nerve injury and pain in the lower back. In such cases, the nucleus pulposus in the herniated disk overproduces certain factors known as cytokines -- notably tumor necrosis factor (TNF) -- that, in high levels, cause inflammation and cell damage. Evidence now suggests that such cytokines cause a biochemical reaction in the regions surrounding the bulging or protruded nucleus pulposus, which results in pain.

Abnormalities in the Annular Ring. Research has also focused on tears in the annular ring -- the fibrous band that surrounds and protects the disk. The annular ring contains a dense nerve network and high levels of peptides that heighten perception of pain. Tears in the annular ring are a frequent finding in patients with degenerative disk disease. Some cases of chronic low back pain may be caused by inward growth of nerve fibers into the annular ring, which triggers pain within the intervertebral disk.

At some time, up to 40% of people have pain called sciatica. This condition occurs when the sciatic nerve is trapped or inflamed.

The Sciatic Nerve. The sciatic nerve has an extensive pathway.

It first branches from the nerve roots that descend off the lowest part of the spinal cord (in the lumbar and sacral areas). Each of the two branches of the sciatic nerve is about as wide as a thumb.
Each branch of the nerve threads through the pelvis and deep into either side of the buttocks.
The nerve branches then pass down each hip and along the back of each thigh to the foot.

Causes of Sciatica. A herniated disk pressing on the sciatic nerve is the most common cause of sciatica, although spinal stenosis or other vertebral abnormalities that press on the sciatic nerve can also cause pain.

The main nerve traveling down the leg is the sciatic nerve. Pain associated with the sciatic nerve usually originates when nerve roots in the spinal cord become compressed or damaged. Symptoms can include tingling, numbness, or pain that radiates to the buttocks, legs, and feet.

Symptoms of Sciatica

Pain due to sciatica can vary widely. It may feel like a mild tingling, dull ache, or a burning sensation. In some cases, the pain is severe enough to cause immobility.

The pain most often occurs on one side. Some people have sharp pain in one part of the leg or hip and numbness in other parts. The affected leg may feel weak.

The pain often starts slowly. Sciatica pain may get worse:

At night
After standing or sitting for long periods of time
When sneezing, coughing, or laughing
After bending backwards or walking more than 50 - 100 yards (particularly if it is caused by spinal stenosis)

Sciatica pain usually goes away within 6 weeks, unless there are serious underlying conditions. Pain that lasts longer than 30 days, or gets worse with sitting, coughing, sneezing, or straining may indicated a longer recovery.

Other than age-related degenerative disk disorders, injuries in the muscles and ligaments supporting the back are the major causes of low back pain. Of note, is the iliac crest pain syndrome (iliolumbar syndrome), in which there are tears in the ligaments that help support the pelvic bone.

Spinal stenosis is the narrowing of the spinal canal. This typically develops as a person ages and the disks become drier and start to shrink. At some point in this process, any disruption, such as a minor injury that results in disk inflammation, can cause impingement on the nerve root and trigger pain. Pain from spinal stenosis can occur in both legs, or it can be felt as sciatica. Spinal stenosis occurs mostly in the elderly with degenerative osteoarthritis, but it can sometimes be caused by other problems, including infection and birth defects.

Spondylosis is a condition in which the fourth or fifth lumbar vertebrae degenerate or develop small fractures. This condition affects 4 - 6% of the general population, and the rates may be higher in certain populations. As it progresses, the spine can become unstable and lead to spondylolisthesis, in which one vertebra slips forward over the other and causes sciatica. The condition most often occurs in older individuals with women having a higher risk than men. It is also a common cause of back pain from stress fractures in young athletes and can also be due to inherited problems, injury, or bone disease.

Some cases of sciatica pain may occur when a muscle located deep in the buttocks pinches the sciatic nerve. This muscle is called the piriformis. The resulting condition is called piriformis syndrome. Piriformis syndrome usually develops after an injury. In rare cases leg swelling, deep-vein blood clots, or both may occur. Piriformis syndrome is sometimes difficult to diagnose.

Ankylosing spondylitis is a chronic inflammation of the spine that may gradually result in a fusion of vertebrae. Symptoms include a slow development of back discomfort, with pain lasting for more than 3 months. The back is usually stiff in the morning; pain improves with exercise. In severe cases, the patient must continually stoop over. It can be quite mild, however, and it rarely affects a person's ability to work. It occurs mostly in young Caucasians in their mid-20s. The disease is more common in men, but about 30% of the cases are in women. Researchers believe that in most cases it is hereditary. About 20% of people with inflammatory bowel disease and about 20% of people with psoriasis develop a form of ankylosing spondylitis. There are few effective treatments for this potentially disabling disease, although etanercept (Enbrel) and infliximab (Remicade), anti-inflammatory agents known as TNF-blockers, are proving to be beneficial.

Any abnormality in joints, vertebrae, or nerve roots can cause back pain:

The facet (z-joints) joints can wear down. In such cases, pain occurs on arching the back or when walking.
In some cases a segment (consisting of two vertebrae and their common joint and disk) becomes unstable when its parts wear down.
Injury to nerve roots, notably deep root ganglia (nerve cells in the spine whose fibers extend from skin to muscle tissue), may be important in some cases. Some patients may have scar tissue that traps the nerve roots in the lower spine and causes sciatica.

Risk Factors

In most known cases, pain begins with an injury, after lifting a heavy object, or after making a sudden movement. Not all people have back pain after such events, however. In the majority of back pain cases, the causes are unknown.

Some evidence suggests that after episodes of back pain, some people may experience changes in brain structure and chemicals that produce an exaggerated response in nerve cells. In fact, a 2005 study suggested that chronic back pain actually shrinks the brain by as much as 11%. Such brain changes may cause a persistent perception of pain even though the actual injury has healed.

German researchers have found that chronic back pain appears to be linked to tiny structural changes in the brain. Using a specialized imaging method, they learned that persons with chronic back pain seemed to have a different, more complex structure to their brain and more activity in the areas involved in pain processing and emotional responses. It is unclear if the brain changes occurred before the pain or in response to the pain.

A number of conditions may make people more or less susceptible to low back pain.

Intervertebral disks begin deteriorating and growing thinner by age 30. One-third of adults over 20 show signs of herniated disks (although only 3% of these disks cause symptoms). As people continue to age and the disks lose moisture and shrink, the risk for spinal stenosis increases. The incidence of low back pain and sciatica increases in women at the time of menopause as they lose bone density. In older adults, osteoporosis and osteoarthritis are also common. However, the risk for low back pain does not mount steadily with ever-increasing age, which suggests that at a certain point, the conditions causing low back pain plateau.

Inherited Spinal Structure Abnormalities. Many people have a genetic susceptibility to low back pain, usually from inheriting spinal structural abnormalities.

Inherited Weakened Disks. Studies are finding that specific mutations of the COL9A gene may play a role in about 10% of sciatica cases. The gene is normally involved in producing collagen, the protein building block in all structural tissue in the body. When defective, it may cause the disk to be less able to resist compressive forces. One 2001 study found the defective gene was present in twice as many patients with disk problems as in patients without back pain.

The likelihood of experiencing back pain increases as children age. Some studies suggest that pain is more common among girls than boys. A common cause of temporary back pain is carrying backpacks that are too heavy for children. Backpacks should not weigh more than 20% of the child's body weight. They should weigh even less for very young children. Emotional or behavioral problems may also contribute to back pain in children.

Jobs that involve lifting, bending, and twisting into awkward positions, as well as those that cause whole-body vibration (usually due to long-distance truck driving), place workers at particular risk for low back pain. The longer a person continues such a job, the higher the risk. Some workers wear back support belts, but evidence strongly suggests that they are useful only for people who are currently have low back pain. The belts offer little added support for the back and do not prevent back injuries. In one study, workers who wore the belt for prevention reported more back pain than the workers who did not wear them.

A number of companies are developing programs to protect against back injuries. Although studies are mixed on the outcome of company interventions, one analysis suggested that they do have a positive effect. Employers and workers should make every effort to create a safe working environment. Office workers should have chairs, desks, and equipment that support the back or help maintain good posture.

Infections. A number of common and uncommon infections are a cause of back pain. Chronic uterine or pelvic infections can cause low back pain in women. Osteomyelitis is infection in the spine, a rare cause of back pain. Other infections that cause back pain include Lyme disease, septic arthritis, bacterial endocarditis, Reiter syndrome, mycobacterial, fungal arthritis, and viral arthritis. Chlamydia pneumonia, an atypical organism that is a common cause of mild pneumonia in young adults, is now believed to cause widespread inflammation in the body's tissue, including blood vessels, and may be responsible for a number of chronic conditions, including heart disease. Some evidence further suggests it may cause inflammation in arteries of the lower spine and contribute to spinal stenosis.

Many medical conditions are associated with back pain.

Osteoporosis is a disease of the skeleton in which the amount of calcium present in the bones slowly decreases to the point where the bones become fragile and prone to fracture. It usually does not cause pain unless the vertebrae collapse suddenly, in which case the pain is often severe. Studies indicate, however, that the incidence of low back pain and sciatica increase around the time of menopause, and very tiny fractures in the vertebrae caused by osteoporosis may be an undetected cause of back pain in many elderly women.
Osteoarthritis occurs in joints where cartilage is damaged and then destroyed, usually as a result of aging. In reaction to this destruction, the bones associated with the joints develop abnormalities. When osteoarthritis affects the spine, it may damage the cartilage in the disks, the moving joints of the spine, or both. The nerves may become pinched, causing pain and in advanced cases, numbness and muscle weakness. The patient may also experience muscle spasms and diminished mobility.
Inflammatory disorders, such as Crohn's disease and rheumatoid arthritis, can produce inflammation in the spine (sacroiliitis), although the spine is less commonly affected than other locations.
Other conditions that can directly cause pain include fibromyalgia, Paget's disease, Parkinson's disease, abscesses, blood clots, and cancer.
Other medical conditions cause referred back pain, which occurs in conjunction with problems in organs unrelated to the spine (although usually located near it). Such conditions include ulcers, kidney disease (including kidney stones), ovarian cysts, and pancreatitis.

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.

It should be noted, however, that a number of medical conditions, such as lung and heart problems and chronic headaches, commonly occur with low back pain. A causal relationship among them, however, is uncertain.

Persistent low back pain in children is more likely to have a serious cause that requires treatment than back pain in adults. According to one small study, one third of children being treated at a hospital for back pain were found to have serious underlying problems.

Stress fractures (spondylolysis) in the spine are a common cause of back pain in young athletes. Sometimes a fracture may not show up for a week or two after an injury. Spondylolysis can cause spondylolisthesis, a condition in which the spine becomes unstable and the vertebrae slip over each other.

Hyperlordosis is an inborn exaggerated inward curve in the lumbar area. Scoliosis, an abnormal curvature of the spine in children, does not usually cause back pain.

Juvenile chronic arthropathy is an inherited form of arthritis. It can cause pain in the sacrum and hip joints of children and young people. It used to be grouped under juvenile rheumatoid arthritis, but is now defined as a separate problem.

Injuries, benign tumors such as osteoblastoma or neurofibroma and cancers, including leukemia, can also cause back pain in children.

Medications may trigger back pain. For example, anticoagulants can cause bleeding or an internal bruise. Long-term steroid use can cause infection or compression fractures.

Some research is suggesting that some people have motor control abnormalities in the deep muscles near the spine. Such lack of control causes instability in the spine that can lead to pain.

Pregnant women are prone to back pain due to a shifting of abdominal organs, the forward redistribution of body weight, and the loosening of ligaments in the pelvic area as the body prepares for delivery. Tall women are at higher risk than short women. Although some earlier research had suggested that the use of epidurals for pain relief during labor could lead to chronic back pain, studies in 2002 reported no increased risk.

Psychological factors are known to play a strong influential role in three phases of low back pain:

Some evidence suggests preexisting depression and the inability to cope may be more likely to predict the onset of pain than physical problems. For example, a British study reported that people who showed emotional distress at age 23 were nearly twice as likely to suffer from back pain 10 years later. A 2005 study found that a “passive” coping style (not wanting to confront problems) was strongly associated with the risk of developing disabling neck or low back pain.
The perception of pain. Social and psychological factors play a role in the severity of a person's perception of back pain. For example, one study compared truck drivers and bus drivers. Nearly all the truck drivers liked their work. Half of them reported low back pain but only 24% lost time at work. Bus drivers, on the other hand, reported much lower job satisfaction than truck drivers, and these workers with back pain had a significantly higher absentee rate than truck drivers in spite of less stress on their backs. Similarly, another study found that pilots, who generally reported "loving their jobs," reported far fewer back problems than their flight crews. And yet another study reported that low rank, low social support, and high stress in soldiers was associated with a higher risk for disabling back pain.
Chronic pain. Depression and a tendency to develop physical complaints in response to stress also increase the likelihood that acute back pain will become a chronic condition. The way a patient perceives and copes with pain at the beginning of an acute attack may actually condition the patient to either recover or develop a chronic condition. Those who over-respond to pain and fear for their long-term outlook tend to feel out of control and become discouraged, increasing their risk for long-term problems.

Studies also suggest that patients who reported prolonged emotional distress have less favorable outcomes after back surgeries. It should be strongly noted that the presence of psychological factors in no way diminishes the reality of the pain and its disabling effects. Recognizing it as a strong player in many cases of low back pain, however, can help determine the full range of treatment options.

Diagnosis

Because nearly all cases of low back pain clear up in a short time and are not due to serious problems, a medical history and a brief physical examination are almost always sufficient.

Still, with very severe or chronic back pain, it is important that any serious medical causes as well as cauda equina syndrome and progressive nerve damage be ruled out first. If the doctor suspects a serious underlying cause, the approach to determining the origin of back pain involves answering three questions:

Is some general medical disorder present that could be causing the pain?
Are there social or emotional factors that might be intensifying the pain?
Are the nerves in the spine involved in the pain (such as in sciatica)?

Such questions can usually be answered with a medical history and physical examination.

A patient should report any serious health problems and concerns during a medical and family history, especially those listed below.

Previous episodes of back pain
Any injuries or accidents involving the neck, back, or hips
History of cancer
Unexplained weight loss or chronic infection
The frequency, duration, and nature of the back pain
When the back pain occurs
What triggered the pain (such as lifting a heavy object)
Conditions that make the pain worse such as coughing
Any situation that relieves the pain
Urination of bowel movement problems
Other relevant symptoms such as morning stiffness, weakness, or numbness in the legs.

The main goal of a physician exam is to try and determine the source of the pain and to determine limits of movement.

Patients are asked to sit, stand, and walk in different ways (flat-footed, on the toes, and on their heels).
In some cases they are asked to walk on a treadmill to test for weakness in toe or heel walking (which may indicate stenosis).
Patients will be requested to bend forward, backward, and sideways and to twist.
Patients will be asked to lift their leg straight up while lying down. The doctor will also move the patient's legs in different positions and bend and straighten the knees. (Pain caused by sciatica can be intensified by lifting the affected leg straight in the air. It is usually sharp, localized, and accompanied by numbness or tingling. Pain caused by inflammation is duller and more generalized and not affected by lifting a straight leg.)
The doctor may measure the circumference of the calves and thighs to look for muscle deterioration.
To test nerve function and reflexes, doctors will tap the knees and ankles with a rubber hammer. The doctor may also touch parts of the body lightly with a pin, cotton swab, or feather to test for numbness and nerve sensitivity.

Because most patients with back pain are on the mend or completely recovered within 6 weeks, imaging techniques such as x-rays or scans are rarely recommended in the first month unless a tumor, fracture, infection, cauda equina syndrome, or progressive neurologic disease is suspected.

Patients who have the following symptoms or experienced certain events may need imaging studies.

Pain that lasts more than a month
Very severe or progressive pain, numbness
Muscle weakness
A previous accident or injury that might have affected the back
A history of cancer
Indications of an underlying disease such as fever or unexplained weight loss
Pain that occurs in patients over 65 years of age

If these conditions exist, usually an x-ray is used first. If results are inconclusive, either computed tomography (CT) or magnetic resonance imaging (MRI) may be performed. (Ultrasound is not useful.)

X-Rays. Although many patients with acute and uncomplicated low back pain believe that plain x-rays of the spinal column are important in a diagnosis, they are not very helpful in most patients except for reducing anxiety. If pain persists after 6 - 8 weeks, then x-rays are usually warranted. In such cases, x-rays may reveal signs of injury, infection, tumors, stenosis, or changes in the vertebrae that may be causing inflammation or compression on the nerve. There are many different types of x-rays for the spine.

A diskography is an x-ray of the disk. This procedure requires injections into disks suspected of being the source of pain and disks nearby. It can be painful and is generally only used for patients who are undergoing back surgery to identify the location of the injured disk.
An x-ray myelogram is an x-ray of the spine that requires a spinal injection of a special dye and the need to lie still for several hours to avoid a very painful headache. It has value only for select patients with pain on moving and standing. It has largely been replaced by CT and MRI scans.

CT stands for computerized tomography. In this procedure, a thin x-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the doctor.

Magnetic Resonance Imaging (MRI). Magnetic resonance imaging (MRI) can provide very well-defined images of soft tissue and bone. It is not painful, but some people may feel claustrophobic in scanners that are fully enclosed. MRIs can detect annular tears, or disk fragments, and non-spinal causes of back pain, including infection and cancer. However, MRIs are no more effective than x-rays in identifying arthritis, and they are more expensive. Some medical evidence suggests that relying on MRI images of disk abnormalities to determine treatment has resulted in many unnecessary surgeries. At least 40% of all adults have bulging or protruding vertebral disks, and most have no back pain. The degree of disk abnormalities revealed by MRIs often have very little to do with the severity of the pain or the need for surgery. Disk abnormalities in people who have back pain may simply be a coincidence rather than an indication for treatment.

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

Advanced imaging techniques should be used only when underlying infection, cancer, or nerve involvement is suspected.

Magnetic Resonance Neurography. This imaging exam looks at the nerves in the pelvic area. Researchers reporting in the Journal of Neurosurgery found that it helped reveal pinched nerves that can cause leg pain. The findings could lead to new ways to diagnose sciatica and piriformis syndrome.

Bone Scintigraphy and SPECT Imaging.In rare cases, doctors may use bone scintigraphy (bone scanning) to determine abnormalities in the bones. The technique may be useful for early detection of spinal fractures, cancer that has spread to the bone, or osteoarthritis. During this exam, a small amount of radioactive material is injected into a vein. It circulates through the body, and is absorbed by the bones. The bones can then be visualized using x-rays or single photon emission computed tomography (SPECT). A study in the February 2006 journal Radiology found that SPECT can help determine which patients would get low back pain relief from spinal injections. Forty-seven patients were randomly divided into two groups: One group received SPECT before they were scheduled for an injection, the other group did not. Those who showed spinal problems on the SPECT images received an injection in the area of the abnormalities. Those who had a normal SPECT, as well as those who did not have the test at all, received injections in the area recommended by their referring physician. After a month, those who had targeted injections using the SPECT images had greater pain relieve than those who did not.

Electrodiagnostic tests that analyze the electric waveforms of nerves and muscles may be useful for detecting nerve abnormalities that may be causing back pain and identifying possible injuries. They are also useful to determine if any abnormal structural findings on an MRI or other imaging test have real significance as a cause of the back pain. It should be noted that any nerve injuries that affect these tests may not be present for 2 - 4 weeks after symptoms begin.

Nerve conduction studies and electromyography are the electrodiagnostic tests most commonly performed.

Nerve Conduction Studies. To perform nerve conduction studies, surface electrodes are attached to the skin. Small electric shocks are then applied to measure the speed of nerve conduction.

Electromyography. To perform electromyography, a fine, sterile, wire electrode is inserted briefly into a muscle and the electrical activity is displayed on a viewing screen. Electromyography can be quite painful, and some experts question, in fact, whether it adds any valuable diagnostic information. They suggest it be limited to unusual cases or when other tests indicate that the condition is aggressive and may increase the risk for rapid, significant injury.

Blood and urine samples may be used to test for infections, arthritis, or other conditions.

Injecting a drug that blocks pain into the nerves in the back helps locate the level in the spine where problems occur.

A procedure called a facet block is also useful in locating areas of specific damage.

Provocative diskometry is a test that uses an injection of saline solution into the suspected disk to reproduce the pain, which is then followed by injection of an anesthetic to dull the pain.

Medications

The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Evidence suggests that short-term use of NSAIDs brings effective relief in patients with acute back pain. The benefits for chronic back pain are less certain.

There are dozens of NSAIDs. The most common are the following:

Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT).
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), dexibuprofen (Seractil), and indomethacin (Indocin).
Topical NSAIDs delivered in gels, creams, or patches do not appear to provide any long-term benefits in reducing arthritic pain.

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

In April 2005, the FDA asked drug manufacturers of prescription NSAIDs to place an alert on their medicines warning people that the drugs have been linked to an increased risk for cardiovascular events and gastrointestinal bleeding. The FDA also requested manufacturers of OTC NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and gastrointestinal risks. Aspirin does not contain such warning labels.

Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the second most common cause of ulcers and the rate of NSAID-caused ulcers is increasing. Ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are also more likely to bleed than those caused by the bacterium H. pylori.

Doctors cannot predict which patients taking these drugs will develop bleeding.

Among the groups at high risk for bleeding are elderly people, anyone with a history of ulcers of GI bleeding, patients with serious heart conditions, alcohol abusers, and those on certain medications, such anticoagulants ("blood thinners"), corticosteroids, or bisphosphonates (drugs used for osteoporosis).

Proton-pump inhibitors may help to prevent and heal ulcers caused by NSAIDs. Proton-pump inhibitors include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid).

An ulcer is a crater-like lesion on the skin or mucous membrane that is caused by an inflammatory, infectious, or cancerous condition. To avoid irritating an ulcer, stop smoking and try to eliminate certain substances from your diet, including caffeine and alcohol. Prescription medicines are available to suppress the acid in the stomach that causes erosion of the stomach lining. Endoscopic therapy can be used to stop ulcer-related bleeding.

Coxibs block an inflammation-promoting enzyme called COX-2. This drug class was initially thought to work as well as NSAIDs, while causing less gastrointestinal distress. However, following numerous reports of cardiovascular events, gastrointestinal problems, and skin rashes, the FDA is currently re-evaluating the relative risks and benefits of this drug class. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the United States market. Celecoxib (Celebrex) is still available, but patients should ask their doctor if this drug is appropriate and safe for them.

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

Narcotics are pain-relieving and sleep-inducing drugs that act on the central nervous system. They are the most powerful medications available for the management of pain.

There are two types of narcotics:

Opiates are derived from natural opium such as morphine and codeine.
Opioids are synthetic drugs and include oxycodone (Percodan, Percocet, Oxycontin), hydrocodone (Vicodin), and oxymorphone (Numorphan).

Novel ways to deliver pain medicine have been developed. A skin patch containing an opioid called transdermal fentanyl (Duragesic) may relieve chronic back pain more effectively than oral opioids. For very severe pain, a small, patient-controlled pump called SynchroMed may be used. This device is implanted under the skin in the abdomen and delivers pulses of pain-relieving opioids to the spinal canal.

Common side effects of opioids include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.

Injections of different substances are sometimes used to treat low back pain caused by nerve impingement. The injection is usually an epidural, which is directed into the spaces between the outer membrane of the spine and the vertebrae. None of these substances cure the problem.

Corticosteroids. An injection of a corticosteroid (commonly called a steroid) is directed as close to the injured location as possible. Corticosteroids reduce inflammation. This approach may temporarily relieve sciatic pain until the body heals itself. Studies that measure the benefits of steroids on sciatica or low back pain are conflicting. There is some evidence that patients can experience rebound pain within a few months. Some experts have also raised concerns that even a single injection can cause serious and painful side effects, including meningitis and inflammation, although such risks are very low.
Hypertonic saline (salt water solution). Epidural injections of saline are being investigated for breaking up scar tissue. One 2001 study compared targeted injections of saline and steroids directed at the nerve root. Although steroid injections had more immediate benefits, both products offered improvement. By the third month, patients who had saline injections experienced less pain than the steroid group. A 2003 study found that epidural corticosteroid injections provided no greater benefit than saline injections for patients with sciatica.
Local anesthetics. Injections of anesthetics such as Xylocaine or bupivacaine may help some patients, although studies on their benefits are mixed.
Botulinum. Researchers are investigating whether injections of botulinum toxin (Botox) in the lower back can safely and effectively relieve pain. Very small amounts of Botox temporarily paralyzes muscle tissue. Botox is commonly used to smooth out wrinkles. Some studies have suggested that Botox may be very helpful in relieving chronic low back pain and sciatica caused by piriformis syndrome. In a 2001 study, the benefits of Botox injections for low back pain subsided within 6 months.

A 2002 review of studies concluded that antidepressants may lessen pain severity in some patients, although they had little effect on daily functioning. Antidepressants called tricyclics can be effective painkillers in non-depressed people with chronic back pain. Such antidepressants include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomil). It should be noted that tricyclics can have severe side effects. Nonetheless, experts believe there is a useful role for these drugs that warrants further investigation.

A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) are sometimes used for patients with acute low back pain. Medical evidence has found that they can help relieve non-specific low back pain, but some experts have warned that these drugs should be used cautiously, since they target the brain, not the muscles. Patients who take muscle relaxants may experience a number of central nervous system side effects such as drowsiness. The muscle relaxant Soma can be addictive and does little more than produce sleep.

Tumor-Necrosis Factor (TNF) Modifiers. TNF modifiers block the action of tumor necrosis factor, a protein involved in inflammatory response. Because of their anti-inflammatory properties, TNF modifier drugs are being investigated for the treatment of the nerve dysfunction and pain that occurs in sciatica. Some small studies indicate that infliximab (Remicade) may help reduce sciatica pain. Early studies suggest that another TNF modifier, etanercept (Enbrel), may be useful for treating sciatica and back pain. TNF modifiers are powerful drugs that can cause severe side effects.

Lidocaine Patch. A skin patch containing lidocaine, a local anesthetic, has been used specifically for herpes zoster pain. Early studies suggest that this patch, called Lidoderm, may provide significant relief for people who suffer from low back pain with very few adverse effects, even with continuous use of four patches a day. If further studies support its benefits, the patch could prove to be an important treatment

NO-NSAIDs. NO-NSAIDs are drugs that combine NSAIDs and nitric oxide (NO), a substance that enhances blood flow to the stomach and increases levels of protective mucus and bicarbonate. These agents show particular promise in providing pain relief and reducing the risk for GI problems.

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

Most herbal remedies used for back pain have both pain-relief and anti-inflammatory effects. Popular herbs for back pain relief include:

White willow bark (Salix alba) contains salicylates, the same chemicals found in aspirin.
Bromelain is an enzyme found in pineapple.
Boswellia (Boswellia serrata) is an herb commonly used in Indian Ayurvedic medicine.
Devil’s claw (Harpagophytum procumbens) is an African herb sometimes used to relieve arthritic pain.

White willow bark, bromelain, and Boswellia have blood-thinning properties and can interfere with anticoagulant medications such as warfarin (Coumadin).

Complementary and Alternative Medicine

A number of complementary and alternative treatments are used to relieve back pain. Complementary means it is used together with conventional medicine. Alternative means it is done in place of conventional medicine.

Acupuncture is now a common alternative treatment for certain kinds of pain. It involves inserting small needles or exerting pressure on certain "energy" points in the body. When the pins have been placed successfully, the patient is supposed to experience a sensation that brings a feeling of fullness, numbness, tingling, and warmth with some soreness around the acupuncture point. Unfortunately, rigorous studies of acupuncture are difficult to perform, and most evidence on its benefits is weak. In any case, it may be specifically helpful for certain patients with back pain, such as pregnant women, who must avoid medications. Anyone who undergoes acupuncture should be sure it is performed in a reputable location by experienced practitioners who use sterilized equipment.

Click the icon to see an image of acupuncture.

A number of well-conducted studies have supported the benefits of massage therapy for patients with chronic or acute back pain, especially when it is combined with exercise and patient education. In fact, one analysis in 2003 suggested it may reduce the costs of care. However, it is usually not covered by insurance.

According to a 2001 review of studies, only intensive programs that include both psychological and physical rehabilitation therapies were successful in reducing chronic low back pain and improving function. A number of effective approaches to low back pain -- collectively called mind-body techniques -- employ psychological, behavioral, or physical methods to promote relaxation and reduce stress. Although many may be helpful, evidence is lacking on the specific approaches that would be most successful and which patients would most likely benefit.

Stress Reduction. Stress reducing techniques, including relaxation methods and meditation, may be helpful. One study, for example, reported that meditation was beneficial in reducing pain and improving mood among chronic pain sufferers who had not responded to traditional care. Another found that after 3 weeks, patients who were in pain after back surgery had less discomfort and slept better after practicing relaxation imagery techniques while listening to music for 25 minutes a day.

Cognitive-Behavioral Therapy. Studies report that a course of cognitive-behavioral therapy helps reduce chronic back pain or at least enhances the patient's ability to deal with it. The primary goal of this form of therapy in such cases is to change the distorted perceptions that patients have of themselves and their approach to pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that pain is only one negative and, to a degree, a manageable experience among many positive ones. In one study, therapists also taught relaxation techniques and methods to improve posture. The sessions lasted for 2.5 hours each week for 12 weeks. More research is needed.

Patient Education and Support Groups. A 2002 study reported that patients with chronic low back pain who participated in an expert-moderated e-mail support and discussion group had less pain and disability after 12 months. An Australian massive public-health campaign that educated patients and doctors about the importance of staying active and dispelled fears about long-term impairment from back pain dramatically reduced disability and worker compensation claims.

Spinal Manipulation for Uncomplicated Acute Low Back Pain. Spinal manipulation may be useful for acute back pain that persists beyond 2 - 3 weeks. There are a number of variations, but one example of a spinal manipulation technique is the following:

The patient first lies on their side.
The practitioner grasps the exposed shoulder and either the hip or knee and then presses the upper and lower portions of the body in opposite directions, so that the torso rotates.
The shifting vertebrae make a cracking or popping sound, indicating that they have exceeded the normal range of motion.
Often this results in a greater sense of ease and mobility. (The effect, however, may be temporary.)

Whether on-going manipulations relieve pain better that just one visit is a subject of debate. Some patients consider spinal manipulation to be highly effective for chronic low back pain. A major 2003 analysis, however, reported that current evidence did not support the benefits of spinal manipulation over general medical care or physical therapy for either acute or chronic back pain. [It was better than sham (fake) therapy, however.]

Spinal manipulations are typically performed by chiropractors, but osteopathic doctors also perform them.

One in three people with low back pain seek treatment from a chiropractor. Chiropractic was founded in the U.S. in the late 1800s. The specific goal of chiropractors is to perform spinal manipulations to improve nerve transmission. Many studies have now confirmed that patients feel more satisfied with their chiropractic care than with treatment from general practitioners.
Osteopathy was also founded in the 1800s. Its core approach to healing also involves physical manipulation. Osteopathy manipulates the bones, muscles, and tendons to optimize blood circulation. The general direction of osteopathy over the years has widened to employ a broader range of treatments that now approach those of standard medicine. One 1999 study reported that osteopathy was as effective as medical treatment in relieving low back pain and patients required far less medication and physical therapy. Osteopathic treatment was also far less expensive than traditional back pain treatments.

Both chiropractors and osteopaths offer verbal assurance and a precise treatment regimen. The direct physical connection through spinal manipulation reinforces the patient-practitioner relationship. The emotional effects of such connections may be as important for healing as the treatments themselves.

Mild and temporary side effects from spinal manipulation are common. The potential for serious adverse effects from low back manipulations is low. It should be strongly noted, however, that serious complications (including stroke or spinal cord or neck injury) have been reported with manipulations of the neck. Although little research has been done on such complications, an English survey indicated that they are more frequent than commonly thought.

Some chiropractors may take a lot of x-rays, particularly those of the full spine, which may have long-term harmful consequences. Patients should also be aware that some chiropractors use alternative treatments that have not been proven or rigorously studied. All patients should require objective evidence on the benefits of their treatments.

Vertebral Axial Decompression. Vertebral axial decompression (VAX-D) may reduce pain and improve function in patients with chronic low back pain, including sciatic pain that radiates down the leg. The patient lies face down on a special table, clutching hand grips and wearing a pelvic harness. The traction-like action alternately decompresses and relaxes the spine over 1-minute intervals. Each session lasts about 30 minutes. Ten to 20 sessions on successive days are often required. The procedure is thought to alleviate pain and enhance healing by relieving pressure within the disks, promoting the in-flow of oxygen, fluids, and nutrients to the spinal column. Some evidence supports its benefits, with reported success rates of around 70%. Because it is considered experimental, it is not yet covered by most insurers. More studies are needed to confirm its possible benefits.

Percutaneous Neuromodulation Therapy. A technique called percutaneous neuromodulation therapy (PNT) uses a small device delivers electrical stimulation to deep tissues and nerve pathways near the spine. It has shown some initial promise for relief of chronic back pain and may also improve mobility and sleep. Treatment sessions are conducted in the doctor's office and last about 30 minutes. A correct pattern of stimulation appears to be important for optimal relief and needs to be determined.

Electric Nerve Stimulation. Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress back pain. A variant, percutaneous electrical nerve stimulation (PENS), applies these pulses through a small needle to acupuncture points. The standard procedure is to give 80 - 100 pulses per second for 45 minutes three times a day. The patients are barely aware of the sensation. Although a 2002 analysis of trials could find no direct evidence of benefit, small studies have reported some relief for chronic low back pain from either TENS or PENS. It is not known if these effects are long lasting. Neither approach is helpful for relief of acute low back pain in most patients.

Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax then the process is stopped. Discomfort is minimal. Small studies are reporting some help in relieving a number of condition the cause chronic pain, including low back pain.

Therapeutic ultrasound. Therapeutic ultrasound involves placing a small wand or probe directly onto the skin. The wand gives off sound waves, which gently vibration the area. Scientists in England are studying whether therapeutic ultrasound may help relieve pain and disability due to sciatica.

Intradiscal Electrothermal Treatment (IDET). Intradiscal electrothermal treatment (IDET) uses electricity to heat a painful disk. Heat is applied for about 15 minutes. Pain may temporarily feel worse, but after healing, the disk shrinks and becomes desensitized to pain. However, healing takes several weeks. The surgery may not work in obese patients.

Some studies have reported positive benefits to IDET; others say it does not significantly reduce pain. A randomized, blinded study published in the November 2005 journal Spine found that IDET was no better than a sham (fake) procedure in relieving chronic back pain due to disk disease. For the study, patients were randomly selected to receive either IDET or a sham procedure. After 6 months, there was no difference in pain symptoms between the two groups.

Exercise and Physical Therapy

Incorrect movements or long-term high-impact exercise is often a cause of back pain in the first place. People vulnerable to back pain should avoid activities that put undue stress on the lower back or require sudden twisting movements, such as football, golf, ballet, and weight lifting.

Exercise does not help acute back pain. In fact, overexertion may cause further harm.

An incremental aerobic exercise program (such as walking, stationary biking, swimming) may begin within 2 weeks of symptoms. Jogging is usually not recommended, at least not until the pain is gone and muscles are stronger.

Patients should avoid exercises that put the lower back under pressure until the back muscles are well toned. Such exercises include leg lifts done in a facedown position, straight leg sit-ups, and leg curls using exercise equipment.

In all cases, patients should never force themselves to exercise if, by doing so, the pain increases.

Exercise plays a very beneficial role in chronic back pain. Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support and neutralize the spine. Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but they also alter and improve patients' attitudes toward their disability and pain. Exercise may also be effective when combined with a psychological and motivational program, such as cognitive-behavioral therapy.

There are different types of back pain exercises. A 2005 review in the Annals of Internal Medicine found that stretching exercises worked best for reducing pain, while strengthening exercises were best for improving function.

Back pain exercises include:

Low Impact Aerobic Exercises. Low-impact aerobic exercises, such as swimming, bicycling, and walking, can strengthen muscles in the abdomen and back without over-straining the back. Programs that use strengthening exercises while swimming may be a particularly beneficial approach for many patients with back pain. Medical research has shown that pregnant women who engaged in a water gymnastics program have less back pain and are able to continue working longer.
Lumbar Extension Strength Training. Exercises called lumbar extension strength training are proving to be effective. Generally, these exercises attempt to strengthen the abdomen, improve lower back mobility, strength, and endurance, and enhance flexibility in the hip and hamstring muscles and tendons at the back of the thigh.
Yoga, Tai Chi, Chi Kung. Practices originating in Asia that combine low-impact physical movements and meditation may be very helpful. They are designed to achieve a physical and mental balance and can be very helpful in preventing recurrences of low back pain.
Pilates, an exercise practice that uses yoga principles, may be specifically helpful.
Flexibility Exercises. Flexibility exercises may help reduce pain. A stretching program may work best when combined with strengthening exercises.
Retraining Deep Muscles. Some studies suggest a link between low back pain and impaired motor control of deep muscles of the back and trunk. According to these studies, contraction exercises specifically designed to retrain these muscles may be effective for patients with both acute and chronic pain.

Perform the following exercises at least three times a week:

Partial Sit-ups. Partial sit-ups or crunches strengthen the abdominal muscles.

Keep the knees bent and the lower back flat on the floor while raising the shoulders up 3- 6 inches.
Exhale on the way up and inhale on the way down.
Perform this exercise slowly 8 - 10 times with the arms across the chest.

Pelvic Tilt. The pelvic tilt alleviates tight or fatigued lower back muscles.

Lie on the back with the knees bent and feet flat on the floor.
Tighten the buttocks and abdomen so that they tip up slightly.
Press the lower back to the floor, hold for one second, and then relax.
Be sure to breathe evenly.

Over time increase this exercise until it is held for 5 seconds. Then, extend the legs a little more so that the feet are further away from the body and try it again.

Stretching Lower-Back Muscles. The following are three exercises for stretching the lower back:

Lie on the back with knees bent and legs together. Keeping arms at the sides, slowly roll the knees over to one side until totally relaxed. Hold this position for about 20 seconds (while breathing evenly) and then repeat on the other side.
Lying on the back, hold one knee and pull it gently toward the chest. Hold for 20 seconds. Repeat with the other knee.
While supported on hands and knees, lift and straighten right hand and left leg at the same time. Hold for 3 seconds while tightening the abdominal muscles. The back should be straight. Alternate with the other arm and leg and repeat on each side 8 - 20 times.

Note: No one with low back pain should perform exercises that require bending over right after getting up in the morning. At that time, the disks are more fluid-filled and more vulnerable to pressure from this movement.

Physical therapy with a trained professional may be useful if pain has not improved within the first 3 weeks. It is, in fact, important for any person who has chronic low back pain to have an exercise program guided by professionals who understand the limitations and special needs of back pain and who can address individual health conditions. One study indicated that patients who planned their own exercise did worse than those in physical therapy or doctor-directed programs.

Physical therapy typically includes the following:

The first stage involves patient education and training the patient in correct movement. Sometimes heat or electro-therapies (such as therapeutic ultrasound or low-energy lasers) are used, although their benefits are unproven.
If back pain persists beyond 5 weeks, physical therapy is used for rehabilitation. It uses exercises to help the patient keep the spine in neutral positions during all daily activities.

Surgery

Diskectomy is the surgical removal of the diseased disk. The procedure relieves pressure on the spine. It has been performed for 40 years with increasingly less invasive techniques being developed over time. However, few studies have been conducted to determine its real effectiveness. In appropriate candidates it provides faster immediate relief than medical treatment, but long-term benefits (over 5 years) are uncertain. A number of minimally invasive variations are now available.

When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk, it is called a slipped disk. Most slipped disks (herniated disks) take place in the lumbar area of the spine. Slipped disks are one of the most common causes of lower back pain. The mainstay of treatment is an initial period of rest with pain and anti-inflammatory medications followed by physical therapy. If pain and symptoms persist, surgery to remove the herniated portion of the intervertebral disk may be needed.

Microdiskectomy. Microdiskectomy is the current standard procedure. It is performed through a small incision (1 to 1-1/2 inch). The back muscles are lifted and moved away from the spine. After identifying and moving the nerve root, the surgeon removes the injured disk tissue under it. The procedure does not change any of the structural supports of the spine, including joints, ligaments, and muscles.

Other less invasive procedures that are available including the following:

Endoscopic Diskectomy. Endoscopy employs a catheter (a thin tube) that contains tiny cameras and surgical instruments that are inserted through small incisions. Various endoscopic approaches are proving to be useful for back surgery.
Percutaneous Diskectomy. Percutaneous diskectomy (PAD). This approach uses a tube with a device at the tip that cuts away some of the nucleus pulposus and a vacuum that then sucks this gelatinous matter out.
Laser Diskectomy. A number of investigative surgical procedures employ lasers. For example, endoscopic laser foraminoplasty (ELF) uses lasers to locate the likely source of pain and remove diseased tissue. The incision requires little more than a Band-Aid and complications are minimal. Long-term benefits are unknown, however.

It is not clear yet if any of these less-invasive procedures are any more effective than the standard microdiskectomy.

Complications and Outlook. Many patients still have back pain after diskectomy that delays discharge from the hospital. Narcotics are usually needed. Adding an injected NSAID may speed resolution of pain.

Scar tissue is a significant problem, since it can cause persistent low back pain afterward. Anti-scarring agents or certain devices may help reduce surgical scars and thereby postoperative pain. Other complications of spinal surgery can include nerve and muscle damage, infection, and the need for reoperation.

Patients now often remain in bed only 3 - 4 days after disk surgery. It may take 4 - 6 weeks for full recovery, however. Gentle exercise may be recommended at first. Starting intensive exercise 4 - 6 weeks after a first-time disk surgery appears to be very helpful for speeding up recovery.

Operations that remove a vertebra (laminectomy) or shave off part of one (laminotomy) may be used in certain cases of spinal stenosis or spondylolisthesis to decompress the nerve. They may also be used to remove benign tumors on the spine.

Click the icon to see an illustrated series detailing lumbar spinal surgery.

Although either procedure often brings immediate relief from pain, a 1999 statistical study suggested that it is inappropriately performed in 60% or more of sciatica cases. There are small risks to the operation, and it is not always successful. Some recurrence of back pain and sciatica occurs in half to two-thirds of postoperative patients. Minimally invasive variations are under investigation.

In cases where abnormal vertebrae position or movement is responsible for severe and chronic back pain, such as spinal stenosis or spondylolisthesis, surgeons may fuse vertebrae together. Fusion uses a bone graft or some other device to join the vertebrae together. In a 2001 study of patients with severe long-term back pain, 33% of patients who had spinal fusion had less back pain after 2 years, compared to 7% who received conservative treatment with physical therapy. Pain improved most in the 6 months following surgery. However, a 2005 clinical trial found that spinal fusion surgery worked no better than intensive rehabilitation in reducing disability. The intensive rehabilitation program included both physical and cognitive-behavioral therapy.

Many spinal fusion surgeries use a tiny hollow metal cage, which is implanted into the disk space. Bone is then removed from the patient's hip and packed inside the cage. Over time the bone grows through the holes and around the device, fusing the vertebrae. Alternatively, rather than performing a bone graft, the cage is filled with a sponge-like material containing a genetically-engineered protein called InFuse (rhBMP-2) that promotes bone to grow.

Click the icon to see an illustrated series detailing spinal fusion.

A number of video-assisted techniques have been developed. The new techniques are less invasive than standard "open" surgical approaches, which uses wide incisions. To date, however, the newer procedures have higher complication rates than the open approaches and some medical centers have abandoned them.

Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into vertebrae with compression fractures. It is done under endoscopic and x-ray guidance. The technique is proving useful for stabilizing the spine and relieving pain in patients with spinal compression fractures due to osteoporosis or cancer. A Mayo Clinic study found that patients who have the procedure have less back pain during rest and activity. A survey of records from more than 100 vertebroplasty patients revealed that most patients are more functional than before the procedure, and the benefits lasted for up to a year. Warning: The FDA has warned consumers that polymethylmethacrylate bone cement, used during vertebroplasty, could leak. Such leakage could cause damage to soft tissues and nerves. It is extremely important that the patient is sure that the health care provider has had significant experience performing the vertebroplasty procedure.

Percutaneous kyphoplasty. The health care provider injects bone cement into the space surrounding a fractured vertebra. (Vertebroplasty injects the cement directly into the vertebra.) Kyphoplasty is used to stabilize the spine and return spinal cord height to as normal as possible. However, a review published in 2006 by a nonprofit health services research agency found that the technique does not improve a person's back pain or quality of life. Kyphoplasty should only be done if bed rest, medicines, and physical therapy do not relieve back pain. Those with severe fractures or spinal infections should not have kyphoplasty.

Artificial Disk Replacement. Total disk replacement is an investigative procedure for some patients with severely damaged disks. The technique implants artificial disks (ProDisc, Link, SB Charite) consisting of two metal plates and a soft core. The surgery can be performed using a minimally invasive laparoscopic procedure, which is performed through tiny cuts using miniature tools and viewing devices. A study in 2003 was the first to suggest that it may eventually achieve results that are comparable to standard surgeries for disk herniation. An artificial cushioning device called the prosthetic disk nucleus (PDN) replaces only the inner gel-like core (nucleus pulposus) within the intervertebral space, rather than the entire disk. It is showing promise in early studies.

Nerve Blocks. A number of surgical techniques are available for relieving pain by impairing nerves that are causing pain due to impingement. Medical research has shown that 60% of the patients who received electrical stimulation to block the nerves reported at least 90% relief of pain after a year; 87% reported at least 60% relief.

Other Treatments

Radiofrequency Nerve Destruction. Radiofrequencies are being used to destroy nerves involved in the facet joints (or z-joints), which connect the vertebrae. Evidence is still weak on its benefits. A 2003 analysis suggested that it may be beneficial, however, for relief of neck pain and possibly for low back pain caused by problems in the facets joints. Serious infections have been reported.

Stem cell treatments. Researchers in England have pioneered a new technique to grow new spinal tissue using the patient's own stem cells. Stem cells are the building blocks of specific cells. Every cell in the human body starts (or "stems") from a stem cell. The new tissue will replace damaged spinal tissue and may relieve low back pain. Researchers expect the treatment to enter pre-clinical trials in about 1 year.

Specific Treatment for Acute Low Back Pain

Patients with short-term acute low back pain usually have the best results with the least aggressive treatments. The general approach is as follows:

Patients with no serious underlying cause should stay as active as possible within the limits of the back pain. (Bed rest is not recommended.)
Physical therapy or spinal manipulations may be helpful if pain continues for more than 2 - 3 weeks.
The patient should seek a specialist if pain continues for more than 1 month. (Some patients may need to see a specialist sooner if there is an underlying disorder, nerve damage, or injury.) Back pain due to medical conditions such as arthritis, osteoporosis, or pregnancy either goes away when the underlying condition disappears or is treated.

Home Care Tips for Relieving Pain

Resume normal activity as soon as possible. Bed rest is no longer recommended and may delay recovery. Activities should be done without strain or stretching.
Avoid intense exercise and physical activity, particularly heavy lifting and trunk twisting if there is acute back pain.
Try an over-the-counter nonsteroidal anti-inflammatory such as aspirin or ibuprofen. These medicines often provide significant benefits.
Apply heat (104°) to the painful area. Heat may work better than ibuprofen or acetaminophen. One group of researchers found that people with low back pain who wear low-level heat wraps for 8 hours a day have significant less pain and disability.
Try alternating between hot and cold packs. Some doctors recommend changing from hot to cold every 3 minutes and repeating this sequence three times. Others believe ice packs should be applied first. This routine should be done two or three times during the day. (Note: Heat or cold treatments do not have much effect on sciatica.)
Supportive back belts, braces, or corsets may help some people temporarily, but these products can reduce muscle tone over time and should be used only briefly.
Get plenty of sleep. Healthy sleep plays a vital role in recovery. Avoid caffeine in the afternoon and evening, and unwind before bed by taking a warm bath or practicing relaxation techniques. It is often difficult to get a good night's sleep when suffering from back pain, particularly because the pain can intensify at night. Some people may need medicine to help manage nighttime pain or treat sleeplessness. Lying curled up in a fetal position with a pillow between the knees or lying on the back with a pillow under the knees may help.

Prescription muscle relaxants may help some patients, although their benefits are uncertain. Once started, medications should be taken on a regular schedule in order to maintain consistent effectiveness.

Massage therapy may help relieve both acute and chronic low back pain. Several well-conducted studies have shown some benefit and suggest it may reduce the costs of care. Massage therapy may not be covered by health insurance.

Spinal manipulation may help, although it is not clear if it works any better than physical therapy or general care. Some experts recommend delaying this treatment until pain has persisted for 3 weeks, if possible, since the back pain will most likely have gone away on its own by then.

Acupuncture has not proven to have any value for acute low back pain in most patients, but may provide some help for patients with chronic low back pain.

Be aware of and avoid approaches that are not helpful. Certain approaches may even be harmful for acute low back pain. For example, permanent bipolar magnets (magnet therapies) can deactivate heart devices and must be kept at least six inches away from pacemakers or implantable cardioverter defibrillators. These magnets have gained some popularity as a non-invasive method of relieving pain, but no studies support the claims.

Specific Treatment for Chronic Low Back Pain

Evidence strongly suggests that only intensive treatment, involving both physical and psychological rehabilitation programs, can reduce pain and improve function in patients with chronic low back pain. Even with the best treatments, many patients with chronic back pain fail to have complete pain relief. They often must develop methods for coping with persistent pain.

Early treatments for severe or chronic low back pain are similar to those of acute uncomplicated low back pain.

Pain relievers, particularly non-steroidal anti-inflammatory drugs (NSAIDs), may help relieve symptoms, although they can have severe effects on the gastrointestinal tract over time. Some doctors have recommended long-term opioids for patients with severe chronic pain, but studies suggest they do not improve activity levels and can have significant side effects.

Corticosteroid injections and tricyclic antidepressants may be helpful for some patients.

Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although patients often find it difficult to maintain therapy.

A new type of physical therapy, called Souchard's global postural re-education, helps relieve back pain symptoms due to degenerative disk disease, according to research presented at the 2005 American Academy of Neurology Annual Meeting. The method involves stretching weakened muscles around the spine and stomach. Researchers studied 102 people who had at least 7 months of severe back pain due to disk disease and who had received different types of treatment for more than 6 months. They attended the new physical therapy sessions two times the first week, then once a week for an average of 5 months. Ninety-two percent had significant pain relief and returned to their normal daily activities. The majority of those who had pain relief felt better after 3 weeks, and remained pain free for almost 2 years.

Alternative therapies may help. Transcutaneous electrical nerve stimulation (TENS) and massage may relieve pain. Mind-body techniques such as relaxation and meditation may be help reducing stress-related pain. Cognitive-behavioral therapy helps change behavior and attitudes toward pain.

Acupuncture may provide longer-lasting pain relief than physical therapy, according to a study in the British Medical Journal. For the study, 129 people were given either 6 acupuncture or physical therapy sessions. The study authors cautioned that the benefit of acupuncture greatly depended on the health care provider’s experience. Another study, published in the Archives of Internal Medicine, reported that acupuncture worked better than no treatment at all.

Yoga relieves low back pain better than conventional exercise or self-help books, according to a study published in the December 20, 2005, issue of Annals of Internal Medicine. For the study, 101 adults with low back pain who were randomly assigned to one of three groups. One group attended yoga classes and lessons; the second did aerobics, weight training, and stretching; and third group read a self-help book about back pain. After 12 weeks, those who took yoga could better perform daily activities requiring the back than those in the other two groups. After 26 weeks, those who took yoga had less pain and better back function, and used fewer pain relievers than the others.

Patients should always try all possible non-surgical treatments before opting for surgery. The most common reasons for surgery for low back pain are sciatica and spinal stenosis. Some experts believe that less than 1% of back pain patients need aggressive medical or surgical treatments.

Nevertheless, when it is appropriate, surgery can provide great relief. Many approaches and procedures are available or being investigated. However, there have been few well-conducted studies to determine if any type of back pain surgery works better than others, or if a single procedure is better than no surgery at all.

People who are obese and have low back pain may benefit from surgical weight loss surgery. A study in the journal Obesity Surgery found that bariatric (stomach stapling) surgery significantly improves the degree of disability in morbidly obese patients who have low back pain.

Before having any surgery, it is extremely important that the patient is sure that the surgeon has had significant experience with the procedure.

Nonsurgical Procedures. Patients with herniated disks should try nonsurgical treatments for at least 1 month before considering surgery. Nonsurgical procedures include spinal manipulation, massage therapy, and physical therapy. Patients should wait at least 2 - 3 weeks before using spinal manipulation.

Surgery. According to a 2001 review of studies, about 10% of patients have such bad back pain after 6 weeks that a diskectomy may be considered. Diskectomy is the standard procedure for herniated disks. For many of these patients, surgery may bring significant relief. In one study, 70% of patients with moderate-to-severe sciatica who had had surgery reported improvement. In most patients, the improvement was better than that achieved by 4 years of nonsurgical treatments. It is not clear if surgery maintains its advantage for longer periods of time.

Preventing Falls. Falling is a risk for patients with spinal stenosis. They should avoid alcohol and sedatives. Leg strengthening exercises such as walking and cycling may be helpful.

Nonsurgical Treatments. The use of common pain relievers such as NSAIDs, physical therapy, and spinal injections may be helpful for some patients.

Surgery. If pain is persistent, patients may require surgery, most often a procedure called decompressive laminectomy. Some patients may require spinal fusion as well. Studies suggest that surgery reduces back pain in many patients with spinal stenosis, at least for a few years. However, by 4 years after surgery, 30% of patients have severe pain again, and 10% have another operation. It should be noted that surgery does not always improve outcome and, in some cases, can even make it worse. Surgery can be an extremely effective approach, however, for certain patients whose severe back pain does not respond to conservative measures.

The general approach for patients with piriformis syndrome is corticosteroid injections and physical therapy. Botox injections are showing promise.

In carefully selected patients who do not respond to physical therapy and injections, some studies report dramatic pain relief with a surgical procedure that releases the piriformis muscle.

Prognosis

Most people with acute low back pain are back at work within a month and fully recover within a few months. According to one study, about a third of patients with uncomplicated low back pain significantly improved after a week; two-thirds recovered by 7 weeks.

However, studies now suggest that up to 75% of patients suffer at least one recurrence of back pain over the course of a year. In another study, after 4 years, less than half were symptom-free. Some doctors are approaching the problem as one that is not necessarily curable and which needs a consistent on-going approach.

Specific conditions can determine the rate of improvement:

In the majority of patients with herniated disks, the condition improves (although the actual physical improvement may be slower than the reduction in pain). Researchers attempted to identify factors most likely to predict an elevated risk for recurrent pain and found that only depression was a significant factor in the majority of those who had not recovered.
Spinal stenosis stabilizes in about 70% of cases and worsens in 15%.

Studies have found that when people stay home because of back injury, only 65% are back at work within a week. Nearly 14% are still absent at one month. If someone is on disability for more than 6 months, the chance of them returning to work is only 50%.

Low back pain accounts for significant losses in work days and dollars. In 1990, it cost the U.S. $23 billion in direct medical costs and possibly as much as $85 billion in total costs (such as lost productivity). Chronic back pain has become one of the most expensive causes of disability among workers under the age of 45. One study found that, although severe back pain comprised only 10% of workers compensation cases, it accounted for 86% of compensation costs.

Complications

Certain warning signs should alert a patient to see a doctor immediately for low back pain. Any very severe back pain warrants attention, particularly if any of the following conditions are present:

Being over 50
Recent injury
Severe pain
Pain awakens the person at night
Pain accompanied by fever (possible infection)
Pain increased by lying down
Pain unrelated to movement
Pain lasts for a month, and is accompanied by unexplained fever or weight loss
History or chronic use of corticosteroids
Intravenous drug use
History of urinary tract infection
In children, any severe neck or back pain or pain that persists for more than 3 days

Cauda equina syndrome is the impingement of the cauda equina (the four strands of nerves leading through the lowest part of the spine). It is an emergency condition that can cause severe complications of the bowel or bladder. Cauda equina syndrome is usually caused by massive extrusion of the disk material. It can cause permanent incontinence if not promptly treated with surgery. Symptoms of the cauda equina syndrome include:

Dull back pain
Weakness or numbness in the buttocks, in the area between the legs, or in the inner thigh, backs of legs, or feet. May cause difficulty in standing or stumbling.
An inability to control urination and defecation
Pain accompanied by fever (can indicate an infection)

Prevention

Exercise, diet, stress, and weight all have a significant influence on back pain. Changing certain lifestyle factors can help reduce and, possibly, prevent backaches.

Smokers are at higher risk for back problems, perhaps because smoking decreases blood circulation. The link may also be due to an unhealthy lifestyle in general. A British study found that young adults who were long-term smokers were nearly twice as likely to develop low back pain as nonsmokers.

Sedentary Lifestyle. People who do not exercise regularly face an increased risk for low back pain, especially when they perform sudden, stressful activities such as shoveling, digging, or moving heavy items. Although no definitive studies have been done to prove the relationship between lack of exercise and low back pain, some doctors believe that an inactive lifestyle may be to blame in some cases. Lack of exercise leads to the following conditions that may threaten the back:

Stiff muscles can make it hard to move, rotate, and bend the back.
Weak stomach muscles can increase the strain on the back and cause an abnormal tilt of the pelvis.
Weak back muscles may increase the risk for disk compression.
Obesity puts more weight on the spine and increase pressure on the vertebrae and disks. However, studies report only a weak association between obesity and low back pain.

Improper or Intense Exercise. Improper or excessive exercise may also increase one's chances for back pain.

Some research suggests that over time, high-impact exercise may increase the risk for degenerative disk disease. A survey of people who played tennis, however, found no increased risk for low back pain or sciatica.
Between 30 - 70% of cyclists experience low back pain. One 1999 study reported that 70% of cyclists reported improvement simply by adjusting the angle of the bicycle seat.
Improper exercise instruction and inattention to body movements can lead to back trouble. For example, a single jerky golf swing or incorrect use of exercise equipment (especially free weights, nautilus, and rowing machines) can cause serious back injuries.

The way a person moves, stands, or sleeps plays a major role in back pain.

Maintaining good posture is very important. This means keeping the ears, shoulders, and hips in a straight line with the head up and stomach pulled in. It is best not to stand for long periods of time. If it is necessary, walk as much as possible and wear shoes without heels, preferably with cushioned soles. Use a low foot stool and alternate resting each foot on top of it.
Sitting puts the most pressure on the back. Chairs should either have straight backs or low-back support. If possible, chairs should swivel to avoid twisting at the waist, have arm rests, and adjustable backs. While sitting, the knees should be a little higher than the hip, so a low stool or hassock is useful to put the feet on. A small pillow or rolled towel behind the lower back helps relieve pressure while either sitting or driving.
Riding in and driving a car for long periods of time increases stress. Move the car seat as far forward as possible to avoid bending forward. The back of the seat should not be reclined more than 30 degrees. If possible, the seat bottom should be tilted slightly upward in front. A traveler should stop and walk around about every hour. Avoid lifting or carrying objects immediately after the ride.

Anyone who engages in heavy lifting should take precautions when lifting and bending.

If an object is too heavy or awkward, get help.
Spread your feet apart to give a wide base of support.
Stand as close as possible to the object being lifted.
Bend at the knees, not at the waist. As you move up and down, tighten stomach muscles and tuck buttocks in so that the pelvis is rolled under and the spine remains in a natural "S' curve. (Even when not lifting an object, always try to use this posture when stooping down.)
Hold objects close to the body to reduce the load on the back.
Lift using the leg muscles, not those in the back.
Stand up without bending forward from the waist.
Never twist from the waist while bending or lifting any heavy object. If you need to move an object to one side, point your toes in that direction and pivot toward it.
If an object can be moved without lifting, pull it, don't push.

There are four natural curves in the spinal column: the cervical, thoracic, lumbar, and sacral curvature. The curves, along with the intervertebral disks, help to absorb and distribute stresses that occur from everyday activities such as walking or from more intense activities such as running and jumping.

Resources

www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.aaos.org -- American Academy of Orthopaedic Surgeons
www.arthritis.org -- Arthritis Foundation
www.spine.org -- North American Spine Society
www.apta.org -- American Physical Therapy Association
www.ampainsoc.org -- American Pain Society
www.theacpa.org -- American Chronic Pain Association
www.iasp-pain.org -- International Association for the Study of Pain

References

Apkarian AV, Sosa Y, Sonty S, Levy RM, Harden RN, Parrish TB, et al. Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. J Neurosci. 2004;24(46):10410-10415.

Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R; Spine Stabilisation Trial Group. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ. 2005;330(7502):1233.

Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, et al. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine. 2005;2(2):99-115.

Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005 Nov 1;30(21):2369-77; discussion 2378.

Friedrich M, Gittler G, Arendasy M, Friedrich KM. Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine. 2005;30(9):995-1000.

Frost H, Stewart-Brown S. Acupressure for low back pain. BMJ. 2006 Mar 25;332(7543):680-1.

Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142(9):765-775.

Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142(9):776-785.

Mercado AC, Carroll LJ, Cassidy JD, Cote P. Passive coping is a risk factor for disabling neck or low back pain. Pain. 2005;117(1-2):51-57.

Melissas J, Kontakis G, Volakakis E, Tsepetis T, Alegakis A, Hadjipavlou A. The effect of surgical weight reduction on functional status in morbidly obese patients with low back pain. Obes Surg. 2005 Mar;15(3):378-81.

Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology. 2006 Feb;238(2):693-8.

Ratcliffe J, Thomas KJ, MacPherson H, Brazier J. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. BMJ. 2006 Sep 23;333(7569):626.

Richardson SM, Curran JM, Chen R, et al. The differentiation of bone marrow mesenchymal stem cells into chondrocyte-like cells on poly-L-lactic acid (PLLA) scaffolds. Biomaterials. 2006 Aug;27(22):4069-78.

Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. Comparing Yoga, Exercise, and a Self-Care Book for Chronic Low Back Pain: A Randomized, Controlled Trial. Ann Intern Med. 2005; 143: 849 - 856.

Tao XG, Bernacki EJ. A randomized clinical trial of continuous low-level heat therapy for acute muscular low back pain in the workplace. J Occup Environ Med. 2005 Dec;47(12):1298-306.

Trout AT, Kallmes DF, Gray LA, Goodnature BA, Everson SL, Comstock BA, Jarvik JG. Evaluation of vertebroplasty with a validated outcome measure: the Roland-Morris Disability Questionnaire. Am J Neuroradiol. 2005 Nov-Dec;26(10):2652-7.

Review Date:
3/19/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M., 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

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Back to Basics: Side-Lying Neutral

FitSugar — Wed, 12 Aug 2009 11:00:19 -0700

Working in a neutral spine is a core component of Pilates. That little pun is intended, too, for working in neutral ensures that your back and abs are both engaged, often turning simple ab exercises into core work. There is a side-lying neutral, too. This is important if you're a fan of floor exercises used in Pilates and aerobics classes around the world.

When side lying, the bottom waist tends to touch the ground, curving the spine like a smile-like shape, unleveling the pelvis by raising the top hip. Not only can this position be bad for your back, it oversimplifies many exercises. To find your side-lying neutral:

Lie on your side with the back of your body against the wall, this prevents you from rolling back or leaning forward.
With your heels against the wall, lengthen your top waist by reaching through your heels until your pelvis is level and your bottom waist is pulled from the floor. You will feel your abs engage.
Keep this position as you move your top leg for leg circles or your lower leg for inner-thigh leg lifts. Maintaining side-lying neutral will decrease the range of motion of your leg, but the movement will be concentrated where it should be rather than in your spine.

If you want to test your newfound neutral, try this Pilates inner-thigh workout.

Minutes to a Healthier You: Strengthen Your Core to Center Your Mind

FitSugar — Tue, 28 Jul 2009 03:30:46 -0700

In Summer, both daily and weekly schedules get all out of whack and the lack of structure leaves me feeling uncentered. To combat my emotional unease, I have added a little ab and core work to my morning routine. I am strengthening my physical center, hoping it translates to my mental life. First, I warm up my spine and follow up with some easy ab and back exercises - heel taps in neutral spine, hip-ups (aka reverse crunches), classic crunches, superman - ending with a few elbow planks. While ab work will never replace my morning coffee, I do like starting the day feeling a little stronger and much more connected to my core. Try it tomorrow and see how you feel.

5 Things: Your First Pilates Session

FitSugar — Tue, 04 Mar 2008 03:00:00 -0800

If you are curious about Pilates but want to know a little bit more about what to expect at your first class – here's a list of five concepts you will likely learn early on in your first Pilates session or group class.

Find Your Deep Abs: The focus on the deep abs, aka transverse abdominis, is what makes Pilates so unique, but you need to find those abs before you can work them. These deep muscles can be hard to isolate without squeezing your bum or tucking your pelvis, which are both no-nos in Pilates.
Breathing: Every exhale is a chance to engage your deep abs since they work as you force your exhale. Sounds simple but it takes a little practice. You will also learn how to inhale without tensing your shoulders, which is great for eliminating neck pain.
Neutral Spine: Finding neutral spine is a key part of the Pilates repertoire. You will learn how to keep your spine in neutral alignment (keeping its natural curves) while you breathe and move. Sounds easy, but at first it can be a little like patting your head and rubbing your tummy.

To see two more skills you will learn, read more.

Articulating Spine: Your spine is made up of 26 articulating vertebrae, and you will learn how to move each of those joints. This concept is the opposite of the "neutral position" and works the flexibility, opposed to the stability, of your spine.
Upper Ab Position: You want to be able to lift your head without straining your neck and to find the spot to optimize your upper ab work. This sweet spot is with the tips of the shoulder blades just off the ground and neck rounded as if you are holding an orange between your chin and chest.

Source

Core Concepts: Running

FitSugar — Mon, 23 Feb 2009 10:00:00 -0800

Whether running for fun, fitness, or to be fast, efficiency is key. Having a strong core plays an important part in translating the power of the legs to propelling the entire body forward through space. The deep abs, made up of the transversus abdominis (TVA) and internal obliques, are the keystone for core stabilization. Unfortunately, running bio-mechanics expert Michael Fredericson, Ph.D, found that about 90 percent of runners have weak abs leading to faulty running patterns. Having weak abs can easily translate into "running funny" with too long or too short of steps, or a pelvis that swings from side to side.

The deep abs stabilize the pelvis by keeping it in a neutral position, so that the back of the legs can push your entire body forward, rather than just wasting power just stretching the low abs. A strong core can help make your running more efficient as well as faster. When the weak low abs work in tandem with the spinal muscles these muscles support the torso and give you more endurance too.

Due to our modern and sedentary lifestyle, many folks have weak deep abs because sitting all day leads to slouching, which deactivates the deeps abs. To learn how to reactivate your TVA right now read more.

Sit up straight (since I just said we all slouch too much you had to know that one was coming). Put your hands on your low ribs and inhale, feeling them expand (flare out to the sides). Don't raise your shoulders though (it might take a few times for you to get the hang of this).
Try to keep your low ribs wide as you exhale by pulling your navel to your spine while keeping your spine still. Think of pushing the air out of your lungs with the action of pulling the deeps abs toward the spine. Repeat for a while until it starts to feel "normal."
Keep practicing this action and not only will you start to strengthen your deep abs, you will increase your ability to breathe deeply by opening up the space between your side and back ribs.

Now every time you do any abdominal exercise you want to focus on the deep abs being active. Warm up your abs before you run, jog, walk, use the stair stepper or elliptical. Exercise mindfully and focus on your pelvic stability and keep checking in with your form. The payoff for paying attention? Stabilizing the pelvis during running and other physical activities will help you stay injury free.

Psoriasis

FitSugar — Wed, 08 Oct 2008 17:35:27 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Treatment

Psoriasis that develops on the hands or feet is often very difficult to treat. However, an advanced clinical trial showed that a medication called efalizumab (Raptiva) effectively cleared or nearly cleared moderate-to-severe symptoms in adults after 12 weeks.

Several studies have shown that most people with severe psoriasis who are treated with infliximab (Remicade) have significant improvement in symptoms by week 10. The findings were presented at the 2007 annual meeting of the American Academy of Dermatology.

Continuing etanercept (Enbrel) after 12 weeks improves disease severity without an increase in infections or side effects, according to a study published in the Archives of Dermatology.

Disease classification

The National Psoriasis Foundation has proposed a new way to classify psoriasis. Instead of being grouped as mild, moderate, or severe, the group suggests a new two-tiered system that classifies patients as needing either local or body-wide (systemic) treatment.

Coexisting conditions

Studies from Newfoundland and Germany have revealed increased cases of diabetes, obesity, arthritis, and cancer in patients with psoriasis. Previous research has found an increased risk of heart disease in psoriasis patients. Research is underway to determine if there are genetic links between psoriasis and these conditions.

Severe psoriasis has been linked to a significant increase in a patient's risk of death. A study of more than 713,000 patients showed that severe psoriasis increased mortality by 50%. Such patients should receive comprehensive health examinations to reduce the risk, the authors recommended. Study participants were considered to have severe psoriasis if they required systemic treatment.

Smoking and psoriasis

Introduction

Psoriasis is a chronic skin disorder marked by periodic flare-ups of sharply defined red patches, covered by a silvery, flaky surface. The main disease activity leading to psoriasis occurs in the epidermis, the top five layers of the skin.

The process starts in the basal (bottom) layer of the epidermis, where keratinocytes are made. Keratinocytes are immature skin cells that produce keratin, a tough protein that helps form hair, nails, and skin. In normal cell growth, keratinocytes grow and move from the bottom layer to the skin's surface and shed unnoticed. This process takes about a month.

In persons with psoriasis, the keratinocytes multiply very rapidly and travel from the basal layer to the surface in about 4 days. The skin cannot shed these cells quickly enough, so they build up, leading to thick, dry patches, or plaques. Silvery, flaky areas of dead skin build up on the surface of the plaques before being shed. The underlying skin layer (dermis), which contains the nerves and blood and lymphatic vessels, becomes red and swollen.

Types of Psoriasis

Various forms of psoriasis exist. Some can occur alone or at the same time as other types, or one may follow another. The most common type is called plaque psoriasis, also known as psoriasis vulgaris.

Plaque psoriasis leads to skin patches that start off in small areas, about one-eighth of an inch wide. They usually appear in the same areas on opposite sides of the body.

The patches slowly grow larger and develop thick, dry plaque. If the plaque is scratched or scraped, bleeding spots the sizes of pinheads appear underneath. This is known as the Auspitz sign.

Some patches may become ring shaped (annular), with a clear center and scaly raised borders that may appear wavy and snake-like.

As the disease progresses, eventually separate patches may join together to form larger areas. In some cases, the patches can become very large and cover wide areas of the back or chest. This is known as geographic plaques because the skin lesions resemble maps.

Plaque psoriasis may persist for long periods. More often it flares up periodically, triggered by certain factors such as cold weather, infection, or stress.

Patches most often occur on the:

Elbows
Knees
Lower back

The may also be seen on the:

Upper pelvic bone area
Bottom of the feet
Calves and thighs
Genital areas
Palms of hands

Psoriasis of the scalp affects about 50% of patients. In some cases, the psoriasis may cover the scalp with thick plaques that extend down from the hairline to the forehead.

Psoriasis patches rarely affects the face in adulthood. In children, psoriasis is most likely to start in the scalp and spread to other parts of the body. Unlike in adults, it also may occur on the face and ears.

Psoriatic arthritis (PsA) is an inflammatory condition characterized by stiff, tender, and inflamed joints. Estimates on its prevalence among those with psoriasis range from 2 - 42%. AIDS patients and those with severe psoriasis are at higher risk for developing PsA.

About 80% of PsA patients have psoriasis in the nails. Arthritic and skin flare-ups tend to occur at the same time. It is not clear whether psoriatic arthritis is a unique disease or a genuine variation of psoriasis, although evidence suggests they are both caused by the same immune system problem.

Although patients with psoriatic arthritis tend to have mild skin symptoms, the disease affects the entire body. PsA, therefore, is more serious than the more common plaque psoriasis. Infrequently, the course of PsA has been associated with a syndrome known by the acronym SAPHO, which stands for:

Synovitis (inflammation in the joints)
Acne
Pustule eruptions
Hyperostosis (abnormal bony growths)
Osteolysis (bone destruction)

Some experts group PsA into five forms. The forms differ according to the location and severity of the affected joint:

Symmetric PsA: Symptoms occur in the same location on both sides of the body. It usually affects multiple joints. In about half of the cases, the condition will get worse. The condition is very similar to, but less disabling than, rheumatoid arthritis. The psoriasis itself is often severe.
Asymmetric PsA: This form involves periodic joint pain and redness, usually in only one to three joints, which can be the knee, hip, ankle, wrist, or one or more fingers. The pain does not occur in the same location on both sides of the body.
Distal interphalangeal predominant (DIP): DIP involves the joints of the fingers and toes closest to the nail. It occurs in about 5% of PsA cases.
PsA in the spine: Inflammation in the spinal column (spondylitis) is the primary symptom in about 5% of PsA cases. Such patients may have stiffness and burning sensations in the neck, lower back, sacroiliac, or spinal vertebrae. The spine can be involved in many patients with PsA, even though stiffness and burning sensations in these areas are not the primary symptoms. When it affects the spine, psoriatic arthritis most frequently targets the sacrum (the lowest part of the spine). Movement is difficult.
Arthritis mutilans: This is a severe, deforming, and progressive form of arthritis. It affects less than 5% of PsA cases. It mainly affects the small joints of the hands and feet, but it can also be found in the neck and lower back. Arthritic and skin flares and remissions tend to coincide.

People who start to smoke after developing psoriasis may delay the onset of psoriatic arthritis, according to research presented at the 2007 annual meeting of the Society for Investigational Dermatology. Researchers found that in nonsmokers, the time between psoriasis diagnosis and psoriatic arthritis development was 13 years, compared to 23 among those who started smoking after the onset of psoriasis. Study participants who smoked before developing psoriasis had psoriatic arthritis occur in about 8 years. However, smoking causes serious health problems and should not be considered as a way to delay this type of psoriasis.


Psoriasis Form	Description of Skin Patches	Comments
Guttate Psoriasis	The patches are teardrop-shaped and appear suddenly, usually over the trunk and often on the arms, legs, or scalp. They often disappear without treatment.	Guttate psoriasis can occur as the initial outbreak of psoriasis, often in children and young adults 1 - 3 weeks after a viral or bacterial (usually streptococcal) respiratory or throat infection. A family history of psoriasis and stressful life events are also highly linked with the start of guttate psoriasis. Guttate psoriasis can also develop in patients who have already had other forms of psoriasis, most often in people treated with widely-applied topical (rub-on) products containing corticosteroids.
Inverse Psoriasis	Patches usually appear as smooth inflamed patches without a scaly surface. They occur in the folds of the skin, such as under the armpits or breast, or in the groin.	Inverse psoriasis may be especially difficult to treat.
Seborrheic Psoriasis	Patches appear as red scaly areas on the scalp, behind the ears, above the shoulder blades, in the armpits or groin, or in the center of the face.	Seborrheic psoriasis may be especially difficult to treat.
Nail Psoriasis	Tiny white pits are scattered in groups across the nail. Toenails and sometimes fingernails may have yellowish spots. Long ridges may also develop across and down the nail. The nail bed often separates from the skin of the finger and collections of dead skin can build up underneath the nail.	Over half of patients with psoriasis have abnormal changes in their nails, which may appear before other skin symptoms. In some cases, nail psoriasis is the only symptom.
Generalized Erythrodermic Psoriasis (also called psoriatic exfoliative erythroderma)	This is a rare and severe form of psoriasis, in which the skin surface becomes scaly and red. The disease covers all or nearly all of the body.	About 20% of such cases evolve from psoriasis itself. The condition may also be triggered by certain psoriasis treatments, and other medications such as corticosteroids or synthetic antimalarial drugs.
Pustular Psoriasis	Patches become pus-filled and blister-like. The blisters eventually turn brown and form a scaly crust or peel off. Pustules usually appear on the hands and feet. When they form on the palms and soles, the condition is called palmar-plantar pustulosis.	Pustular psoriasis may erupt as the first occurrence of psoriasis, or it may evolve from plaque psoriasis. A number of conditions may trigger pustular psoriasis, including infection, pregnancy, certain drugs, and metal allergies. It can also accompany other forms of psoriasis and be very severe.

Causes

The precise causes of psoriasis are unknown. It is generally believed to be due to damage in factors in the immune system, enzymes, and other materials that control skin cell division. This prompts an abnormal immune response, which causes rapid production of immature skin cells and inflammation.

The Normal Immune System Response. The inflammatory process is the result of the body's immune response, which fights infection and heals wounds and injuries:

When an injury or an infection occurs, white blood cells are mobilized to rid the body of any foreign invaders, such as bacteria or viruses.
The masses of blood cells that gather at the injured or infected site produce factors to repair wounds, clot the blood, and fight infections.
In the process, the surrounding area becomes inflamed (red and swollen), and some healthy tissue is injured.

The Infection Fighters. The primary infection-fighting units are two types of white blood cells: lymphocytes and leukocytes.

Lymphocytes include two subtypes known as T cells and B cells. Both types of cells are designed to recognize foreign substances (antigens) and launch an offensive or defensive action against them:

B cells produce antibodies, which are designed to attack the antigens. Antibodies can either ride along with a B cell or travel on their own.
T cells have special receptors attached to their surface that recognize the specific antigen.

T cells are further categorized as killer T cells or helper T cells (TH cells).

Killer T cells directly attack antigens found on bacteria or other cells.
Helper T stimulate B cells and other white cells to attack the antigen.

The actions of the helper T cells are of special interest. Researchers have found high numbers of helper T cells in psoriatic plaques. Helper T cells normally stimulate B cells to produce antibodies. In psoriasis, however, they appear to direct the B cells to produce autoantibodies ("self" antibodies), which attack skin cells. In psoriatic arthritis, cells in the joints also come under attack.

Helper T cells also release or stimulate the production of powerful immune factors called cytokines. In small amounts, cytokines are very important for healing. If overproduced, however, they can cause serious damage, including inflammation and injury during the psoriasis disease process. In psoriasis, researchers are particularly interested in cytokines known as GRO-alpha, tumor necrosis factor, and certain interleukins.

Cytokines attract large numbers of other large white blood cells known as neutrophils. Neutrophils stimulate the production of arachidonic acid, producing two key players in the inflammatory process:

Leukotrienes: These chemicals attract even more white blood cells to the inflamed area.
Prostaglandins: These chemicals widen blood vessels and increase blood flow.

A combination of genes is involved with increasing a person's susceptibility to the conditions leading to psoriasis.

HLA Molecules. The processes leading to all autoimmune diseases involve the human leukocyte antigen (HLA) system. HLA molecules pick off parts of antigens and present them on the surface of a cell so that the various infection-fighting factors in the immune system can recognize and destroy them. Most immune disorders, including psoriatic arthritis, are due to problems with this system. For example, psoriasis patients with an HLA genetic factor called HLA-CW6 tend to develop psoriasis at an earlier than average age. However, only 10% of people who have this gene develop psoriasis. Other genetic and environmental factors are required to actually trigger the disease.

PSORs. Researchers have now identified four key genes (named PSOR 1 - 4) that are involved with psoriasis. Of particular interest are the genes located in regions on specific chromosomes that are linked to HLA and tumor necrosis factor, another immune factor strongly associated with psoriasis.

Weather, stress, injury, infection, and medications, while not direct causes, are often important in triggering the disease process leading to the start and worsening of psoriasis.

Weather. Cold, dry weather is a common trigger of psoriasis flare-ups. Hot, damp, sunny weather helps relieve the problem in most patients. However, some people have photosensitive psoriasis, which actually improves in winter and worsens in summer when skin is exposed to sunlight.

Stress and Strong Emotions. Stress, unexpressed anger, and emotional disorders, including depression and anxiety, are strongly associated with psoriasis flare-ups. In one study, nearly 40% of patients remembered a specific stressful event that occurred within a month of a psoriasis flare. Other research has suggested that stress can trigger specific immune factors associated with psoriasis flares.

Infection. Infections caused by viruses or bacteria can trigger some cases of psoriasis. For example:

Streptococcal infections in the upper respiratory tract, such as tonsillitis, sinusitis, and strep throat, are known to trigger guttate psoriasis in children and young adults. The infections may make ordinary plaque psoriasis worse.
Human immunodeficiency virus (HIV) is also associated with psoriasis.
An uncommon form of human papillomaviruses (HPV) called EV-HPV has been associated with psoriasis. Although EV-HPV is probably not a direct cause, it may play a role in the continuation of psoriasis. This HPV form is not the virus associated with cervical cancer and genital warts.

Skin Injuries and the Köbner Response. The Köbner response is a delayed response to skin injuries, in which psoriasis develops later on at the site of the injury. In some cases, even mild abrasions can cause an eruption, which may be a factor in the frequency of psoriasis on the elbows or knees. It should be noted that psoriasis can develop in areas with no history of skin injury.

Medications. Drugs that can trigger the onset of the disease, worsen symptoms, or cause a flare-up include:

Angiotensin-converting enzyme (ACE) inhibitors, drugs used to treat high blood pressure and heart problems
Beta-blockers, drugs used to treat high blood pressure and heart problems
Chloroquine, a medicine used to treat malaria
Lithium for bipolar disorder treatment
Indomethacin, a nonsteroidal anti-inflammatory drug (NSAIDs) -- Note: Other NSAIDs, such as meclofenamate, may actually improve the condition.
Progesterone, used in female hormone therapies

Flare-ups of severe psoriasis may occur in persons who stop taking steroids taken by mouth, or who discontinue use of very strong steroid ointments that cover wide skin areas. The flare-ups may be of various psoriatic forms, including guttate, pustular, and erythrodermic psoriasis. Because these drugs are also used to treat psoriasis, this rebound effect is of particular concern.

Medications that cause rashes, a side effect of many drugs, can trigger psoriasis as part of the Köbner response.

Risk Factors

Between 5.8 and 7.5 million Americans have psoriasis. Risk factors for psoriasis include:

Age under 20. About 40% develop the condition before age 20. Psoriasis (most often plaque psoriasis) can even occur in infants.
Climate. Some studies have found that the disorder develops earlier and more frequently in colder climates. For example, psoriasis occurs more frequently in African-Americans and in Caucasians who live in colder climates than in people of any ethnicity who live in Africa.
Ethnicity. Psoriasis is uncommon in Native Americans of either North or South American descent.
Family history of the disease. About 35% of those with psoriasis have one or more family members with the disorder.
Male gender. Some studies have indicated that more men than women have psoriasis.

Diagnosis

A microscopic examination of tissue taken from the affected skin patch is needed to make a definitive diagnosis of psoriasis and to distinguish it from other skin disorders. Usually in psoriasis, the examination will show a large number of dry skin cells, but without many signs of inflammation or infection. Specific changes in the nails are often strong signs of psoriasis.

Several conditions produce symptoms that resemble those of psoriasis. For example:

Seborrheic psoriasis is hard to distinguish from seborrheic dermatitis (dandruff is one form of this condition). Seborrheic dermatitis patches are usually greasy, yellowish, and crusty. Nail involvement may also help differentiate psoriasis.
Generalized erythrodermic psoriasis may be confused with drug allergic reactions, atopic eczema, and symptoms of lymphomas.
Fungal infections, other skin conditions, or circulation problems may also cause nail changes typical of psoriasis.

Symptoms of psoriatic arthritis may also resemble the following:

Rheumatoid arthritis (RA). As in rheumatoid arthritis, psoriatic arthritis can cause pain or tenderness in one or more joints, and morning stiffness is common. People with psoriatic arthritis, however, lack a particular antibody, called rheumatoid factor, which is found in the blood of many people with rheumatoid arthritis.
Systemic lupus erythematosus (SLE). Symptoms of SLE may include both a psoriasis-like rash and arthritis, which could make the diagnosis difficult.
Reiter's disease. Reiter's disease is a syndrome that includes arthritis and inflammation in the eyes and urinary tract. It also causes skin lesions that are very similar to psoriasis, which are usually raised patches on the lips, penis, palms, and soles.
Gout. Gout causes pain, often in the fingers and toes.

Some evidence now indicates that inflammation in psoriatic arthritis may be distinguished from other arthritic conditions by its occurrence in sites where muscle tissue inserts into the bone (called enthesitis) rather than in the joint, which is a common site in other inflammatory arthritic conditions.

Severity of psoriasis itself ranges from one or two flaky inflamed patches to widespread pustular psoriasis that, in rare cases, can be life threatening. To help determine the best treatment for a patient, doctors usually classify the disease as mild to severe. The classification depends on how much of the skin is affected:

Mild psoriasis affects less than 3% of the body surface. Most cases of psoriasis are limited to less than 2% of the skin.
Moderate psoriasis covers 3 - 10% of the skin.
If more than 10% of the body is affected, the disease is considered severe.

The palm of the hand equals 1% of the body. The severity of the disease is also measured by its effect on a person’s quality of life.

However, the National Psoriasis Foundation has proposed a new classification method. The group suggests a new two-tiered system that classifies patients as needing either local or body-wide (systemic) treatment.

While disease severity impacts treatment success, some forms of psoriasis can be very resistant to treatment even though they are not categorized as severe. They include:

Any psoriasis on the palms and soles (hand and foot psoriasis)
Inverse psoriasis (which occurs in the folds of the skin)
Scalp psoriasis
Psoriatic arthritis

Treatment

Many creams, ointments, lotions, and pills are available for the treatment of psoriasis. Many patients require only over-the-counter treatment, or even none at all during relapses.

About a third of patients with psoriasis, however, do not respond to over-the-counter remedies and lifestyle changes, and require aggressive treatments. In some cases, such treatments need to be lifelong.

In general, there are three treatment options for patients with psoriasis.

Topical medications such as lotions, ointments, creams, and shampoos
Body-wide (systemic) medications, which involve pills or injections that affect the whole body, not just the skin
Phototherapy, which uses light to treat psoriasis lesions

Individual requirements vary widely, and treatment selection must be carefully discussed with the doctor.

Giving treatment in a particular order is a strategy for providing both quick relief of symptoms and long-term maintenance. It involves three main steps:

The quick fix, to clear the psoriatic lesions during an acute outbreak (for example, a high-strength topical steroid in mild-to-moderate psoriasis, or an oral immunosuppressant in more severe cases)
The transitional phase, intended to gradually introduce the maintenance drug
Ongoing maintenance therapy

Choices for transitional or maintenance treatments depend on the severity of the condition. Some examples are described in the following sections.

In severe chronic cases, a doctor may recommend rotational therapy. This approach alternates treatments. The goal is to prevent severe side effects or build-up of resistance from long-term use of a single medicine. An example of a rotational schedule may be the following:

The patient gets phototherapy for about 2 years.
The patient then takes one or two powerful body-wide drugs for 1 - 2 years and stops.
Phototherapy starts again, and the cycle repeats.

Some doctors use the Koo-Menter Psoriasis Instrument (KMPI) to decide which patients should receive a pill or an injection. The KMPI’s questions include:

Does psoriasis cover at least 5% of the patient’s body?
Is the patient disabled by psoriasis?
Does psoriasis affect the patient’s quality of life?

If the answer to these questions is "yes," three additional questions are considered:

Is light therapy inappropriate for the patient?
Is the patient’s psoriasis resistant to light therapy?
Does the patient have psoriatic arthritis?

If the answer to these questions is “yes,” a doctor may decide to prescribe a pill or injected drugs.

Doctors increasingly use combinations of pills, creams, ointments, and phototherapy instead of single medications. Combinations of oral treatments are particularly useful, since the doses of each drug can be reduced. This lowers the risk of severe side effects. Thousands of combinations are possible, and the patient and doctor should discuss the best treatment for individual needs.

Topical Medications

Topical medications are those applied only to the surface of the body. They come in the following forms:

Creams
Foams
Gels
Lotions
Occlusive tapes
Ointments
Shampoos
Solutions
Sprays

In general, topical treatments are the first line for mild-to-moderate psoriasis, but they may also be used, alone or in combination, with more powerful treatments for moderate-to-severe cases. Topical medicines rarely produce complete clearance, however.

Corticosteroid topical treatments are the mainstay of psoriasis treatments in the United States. They work for most patients. Such treatments:

Decrease inflammation
Block cell production
Relieve itching

Corticosteroids are available in a wide range of strengths, and are generally given as follows:

Less potent drugs are used for mild-to-moderate psoriasis.
Stronger drugs are reserved for more severe disease.

In the past, topical steroids have been used twice a day. Studies are reporting, however, that certain drugs may work just as well if taken once a day. Most studies have evaluated high-potency steroids, but one study suggested that those of medium strength, such as triamcinolone (Aureocort, Tri-Adcortyl), may be equally beneficial as a once-daily treatment. However, corticosteroids used alone clear psoriasis in only 4 - 36% of patients.

Combination therapy. Combinations with other drugs are often needed. For example, an effective, topical regimen uses the following combination for maintenance therapy:

A high-potency steroid (such as halobetasol) on the weekend
A vitamin D3 topical medication called calcipotriene, twice daily on weekdays

In one study, more than 75% of patients with mild-to-moderate psoriasis remained in remission for at least 6 months with this regimen.

Side Effects. The more powerful the corticosteroid, the more effective it is. But it also has a higher risk for severe side effects. Side effects may include:

Burning
Irritation
Dryness
Acne
Thinning of the skin; skin may become shiny, fragile, and easily cut
Dilated (widened) blood vessels
Loss of skin color

Loss of Effectiveness. In most cases, the patients become tolerant to the effects of the drugs, and the drugs no longer work as they should. Some experts recommend using intermittent therapy (also called weekend or pulse therapy). This type of treatment involves applying a high-potency topical medication for 3 full days each week.

Note: This list is not all inclusive.
Low potency (some are available over the counter)	Desonide (Tridesilon, DesOwen) Flumethasone pivalate (Locorten) Fluocinolone acetonide (Synalar, Derma-Smoothe) Hydrocortisone (Hytone, Penecort, Synacort, Cort-Dome, Nutracort, Westcort) Triamcinolone acetonide (Aristocort)
Low to medium potency	Alclometasone dipropionate (Aclovate) Hydrocortisone (Locoid, Pandel) Hydrocortisone valerate (Westcort) Prednicarbate (Dermatop)
Medium to upper-mid potency	Clocortolone pivalate (Cloderm) Fluticasone propionate (Cutivate) Mometasone furoate (Elocon) Triamcinolone acetonide (Aureocort, Tri-Adcortyl, Kenalog)
High potency	Betamethasone (Diprosone) Amcinonide (Cyclocort) Desoximetasone (Topicort) Diflorasone diacetate (Florone, Maxiflor) Fluocinonide (Lidex) Halcinonide (Halog)
Very high potency	Halobetasol propionate (Ultravate) Betamethasone (Diprolene, Luxiq) Clobetasol propionate (Temovate, Olux) Diflorasone diacetate (Florone, Maxiflor, Psorcon)

Coal tar preparations have been used to treat psoriasis for about 100 years, although their use has declined with the introduction of topical vitamin D3-related medicines. Crude coal tar stops the action of enzymes that contribute to psoriasis, and helps prevent new cell production. Tar is often used in combination with other drugs and with ultraviolet B (UVB) phototherapy.

Side Effects. Preparations have the following drawbacks:

Stains on clothing
Skin irritation
Sun sensitivity and increased risk of sunburn for up to 24 hours after use

Anthralin (Dritho-Scalp, Drithocreme, Micanol) is related to a medication called chrysarobin, in use since the early 1900s. Anthralin slows skin cell reproduction and can produce remissions that last for months. It is recommended only for chronic or inactive psoriasis, not for acute or inflamed eruptions. Persons with kidney problems should use anthralin with caution.

As with tar, its use has also declined with introduction of the topical vitamin D-related medicines, but newer formulations, such as Micanol, have made its use more tolerable. Micanol (Psoriatec) is an anthralin formulated in microcapsules, which dissolve and allow the drug to be delivered directly to the target skin areas. It is particularly useful for scalp psoriasis, and it is less likely to stain.

Side Effects. Anthralin may cause the following side effects:

Skin irritation and burning
Staining of clothes, hair, fabrics, plastics, and other household products

Patients should not use anthralin on their faces. Fair skinned people should generally avoid it. Triethanolamine (CuraStain) is a chemical that can neutralize anthralin and help reduce irritation from short-contact anthralin treatment. It should be applied 1 or 2 minutes before washing off the anthralin. It is then reapplied after drying the skin.

Washing stained items with hypochlorite (Clorox) detergents can help remove stains. Many people use disposable gloves while applying the treatment to avoid staining hands.

Application. Apply anthralin only to the psoriasis plaques. Rub the cream in well, and wipe off any excess. Wash off only with lukewarm water, not soap. Using hot water will trigger the staining action. A technique called short-contact anthralin therapy (SCAT), also called minute therapy, is useful for local areas of psoriasis. In such cases, anthralin is applied for only 10 minutes to an hour.

A topical form of vitamin D3, calcipotriene (Dovonex) is proving to be both safe and effective. It is now available in a foam preparation, which makes compliance even easier. Several other topical vitamin D3 related drugs showing promise include maxacalcitol (Oxarol), tacalcitol, and calcitriol (Silkis).

Calcipotriene appears to:

Block skin cell reproduction
Enhance the maturity of keratinocytes (the impaired skin cells in psoriasis)
Acts as an anti-inflammatory

It works just as well as moderate topical corticosteroids, short-term anthralin, and coal tar in improving mild-to-moderate plaque psoriasis. Unlike steroids, patients do not develop thinning of the skin or tolerance to the drug.

Using the drug in combination with other topical and systemic treatments may improve effectiveness. Calcipotriene doesn't work as well as the highest potency corticosteroids, but products or regimens that combine both medications are proving to be more effective than either one alone. Taclonex, an ointment containing both calcipotriol and betamethasone, was approved by the U.S. Food and Drug Administration (FDA) in January 2006 for the treatment of adults with psoriasis. Studies show the combination works better than either drug alone.

Combining vitamin D ointments with systemic medicines, notably methotrexate, acitretin, or cyclosporine, increases effectiveness and allows lower doses or either medication, thereby reducing side effects.

Studies also report success in some patients who use vitamin D ointments in combination with phototherapy treatment.

Side Effects. Calcipotriene may cause the following side effects:

A possible lowering of vitamin D levels, which may affect bone growth in some children
A possible increase in blood calcium levels (seen in some people who apply calcipotriene to large areas)
Skin irritation in about 20% of patients, particularly on the face and in skin folds

Calcipotriene appears to cause greater skin irritation than potent corticosteroids. Diluting the drug with petrolatum or applying topical corticosteroids to sensitive areas may prevent this problem.

Retinoids are related to vitamin A. They are used for various skin disorders. Tazarotene (Tazorac) is the first topical retinoid found to be effective for mild-to-moderate psoriasis. It is available in cream or gel form.

Unlike steroids, patients do not develop thinning of the skin or tolerance to the drug. Only a very small amount is needed on each lesion. It can be used on the scalp and nails, but it is not recommended for the genital areas or around the eyes. The gel should be used on only 20% of the body at anytime; the cream on up to 35%. (Note: The palm of the hand is about 1% of the body surface.)

Combining topical retinoids with other psoriasis treatments, such as with topical steroids, works better than using the drug by itself.

Side Effects. Tazarotene may cause dryness and irritation of healthy skin. Applying zinc oxide and moisturizer around the treated area can protect the healthy skin.

At levels high enough to be effective for psoriasis, tazarotene can cause severe skin irritation on treated areas. This medicine, then, is usually used in combination with other treatments, therefore allowing a lower dose. Mixing the drug in equal amounts with petroleum jelly (Vaseline) initially and then gradually increasing the amount of tazarotene may help the skin areas become less sensitive. It should be noted that the skin can become very red while it is actually improving.

Vitamin A derivatives (drugs related to vitamin A) have been associated with birth defects and should not be used by women who are pregnant, who wish to conceive, or who are nursing.

Salicylic acid applied to the skin helps remove scaly plaque and enhance the actions of other medications. It should not be used to cover wide areas of the body, since it can cause nausea and ringing in the ears. Combinations with high potency steroids, such as mometasone furoate (Combisor), clobetasol propionate, and betamethasone, are proving to be very helpful. Only Combisor is available in the United States.

Watertight (occlusive) tapes or wrappings may help heal psoriasis. Occlusive tapes are particularly useful for psoriatic cuts on the palms and soles. In such cases, the tape should be applied across the cuts until they heal.

Occlusive tapes retain sweat, which helps restore moisture to the outer skin layer and prevent scaling. They also protect against abrasion and irritation.

High-Potency Corticosteroid Tapes. Applying a corticosteroid beneath an occlusive tape, or using a tape that already has a potent corticosteroid (Cordran Tape) such as flurandrenolide may be especially beneficial. Studies are showing that high-potency corticosteroid-containing tapes are more effective than using high-potency corticosteroid ointments alone.

However, the tapes are expensive and are associated with a high rate of skin irritation, increased secondary infections, and a greater chance of symptoms relapse after treatment is stopped. Infection risk may be reduced by changing tapes every 12 hours.

The use of corticosteroids under occlusive tapes on large areas of psoriasis also increases the risk for adrenal insufficiency, a sometimes dangerous condition that occurs because the body loses its ability to produce natural steroids. Children are especially vulnerable to this effect.

Other Medications with Occlusive Tapes or Wrappings. The tapes may be used in combination with other medications, such as fluorouracil. Occlusive wrappings are not usually used with tazarotene (Tazorac) and should never be used without a doctor's recommendation.

Numerous topical medications are under investigation. One such medication, tacrolimus (Protopic), is an immunosuppressant that is proving to be useful in allergic skin disorders and is being studied for psoriasis. Studies have been mixed on its benefits, although new delivery methods may make it more effective. It may prove to be safe for sensitive areas, such as the face. Pimecrolimus (Elidel), a similar medication, is also being studied.

Systemic Medications

Systemic treatment uses various medications that affect the whole body, not just the skin. Many systemic drugs used for psoriasis are also used for other severe diseases, including autoimmune diseases (especially rheumatoid arthritis) and cancer.

Systemic treatments for psoriasis may be taken by mouth or injection. The medicines can have significant side effects and are generally reserved for severe psoriasis.

At this time, the only systemic medications specifically approved for psoriasis are:

Cyclosporine
Methotrexate
Retinoids

As with all medications for psoriasis, the patient should use the lowest strength medication first. The primary treatment is called a first-line treatment, the next is known as a second-line treatment, and so on. Combinations of medications are often used.

Methotrexate (Rheumatrex) is a biologic drug that interferes with cell reproduction and has anti-inflammatory properties. It is a first line, or primary, systemic drug used to treat adults with severe psoriasis. The medicine is one of the few systemic drugs proven to help patients with psoriatic arthritis.

The drug is taken weekly, not daily. (Deadly reactions have been reported in people who mistakenly took it once a day.)

Side Effects. Common side effects of methotrexate include:

Anemia
Headache
Mild hair loss
Mouth sores
Nausea
Possible muscle aches
Rash
Vomiting

Many of these side effects are due to folic acid deficiency. Patients should ask their doctor if folic acid supplements (generally recommended at 1 - 5 mg daily) are necessary.

More serious side effects include:

Increased risk for infections, particularly shingles and pneumonia. Methotrexate suppresses the immune system. Patients with active infections should avoid this drug.
Infertility, miscarriage, and birth defects. If used during pregnancy, the drug can cause miscarriages or birth defects in the baby. It may harm fertility in men.
Kidney complications.
Liver damage. In one study, 25% of patients taking methotrexate for 5 years developed scarring of the liver. Those with existing liver problems should not take this medicine, if possible. Regular monitoring for liver toxicity, including blood tests and liver biopsies, is important in patients who take the drug.
Lung disease. This side effect can be sudden and severe, and occurs in up to 5% of people who take methotrexate. Risk factors include diabetes, existing lung inflammation, protein in urine, and use of rheumatoid arthritis drugs called DMARDs.
Lymphomas. A few cases have been reported, which are most likely related to the drug's immune-suppressing (lowering) effects. In most instances, the disease has gone into remission when the drug was stopped. Most studies have found no significant risk for cancers in patients taking methotrexate.
Osteoporosis. Low doses of methotrexate do not appear to have any significant effect on bone loss, but long-term studies are needed to confirm this.
Radiation recall: An uncommon side effect in patients who have previously been burned by radiation cancer treatments or sunburns. In such cases, a flare-up of symptoms occurs in the previously affected skin areas.
Severe anemia. Folic acid supplements can offset this effect.
Toxic effects on bone marrow. This can cause reduced blood cell production.

Despite its side effects, some experts view methotrexate as the best therapy for widespread plaque psoriasis. It may also be effective for some patients with other severe forms of the disease, including psoriatic arthritis, generalized erythrodermic, and pustular psoriasis.

Methotrexate appears to be effective in children, but more safety research is needed.

Drug Interactions. Many drugs interact with methotrexate, occasionally with harmful results. For example, the antibiotic trimethoprim-sulfamethoxazole increases the toxicity of methotrexate.

A serious, harmful reaction can occur if methotrexate is taken with common, nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen. Other NSAIDs, namely ketoprofen, flurbiprofen, and piroxicam, appear to be safe when given with methotrexate and may be used in patients with psoriatic arthritis. Rheumatoid arthritis (RA) patients who take methotrexate often take NSAIDs as well, but methotrexate doses in psoriasis patients are usually much higher than those in RA.

People Who Should Avoid Methotrexate. Pregnant and nursing mothers should never take methotrexate because it increases the risk for severe, even fatal, birth defects and miscarriage. The drug should be discontinued several months before planning a pregnancy. It may also cause temporary impairment of fertility in men.

Persons with the following conditions should also avoid taking methotrexate:

Alcoholism
Anemia or other blood abnormalities
Immunosuppression
Kidney problems
Liver problems (including hepatitis)
Rheumatoid arthritis
Peptic ulcers

Patients at risk for liver complications include those with diabetes and obesity. Anyone with a history of hepatitis should have a liver biopsy before taking methotrexate.

Oral retinoids are vitamin A-related medications taken by mouth. This group of medicines is also a first-line treatment for adults with severe psoriasis. Oral retinoids used for psoriasis include acitretin (Soriatane) and isotretinoin (Accutane).

Acitretin is the retinoid of choice and may be dramatically effective for severe psoriasis, particularly pustular or erythrodermic variants. When used alone, it is much less effective against more common forms, such as plaque or guttate psoriasis. However, combinations with PUVA phototherapy can markedly improve the response even in these patients.

Accutane, more commonly used to treat acne, is far less potent than acitretin, but may still be effective against pustular psoriasis and also be effective with phototherapy.

Oral retinoids help control cell reproduction and have anti-inflammatory properties. They may even improve arthritis that accompanies psoriasis.

Combination therapy. Acitretin may work the best when combined with other treatments, usually topical drugs and especially phototherapy. Combination therapy allows lower doses of oral retinoids to be used, which diminishes many skin and mucous membrane side effects. Acitretin combined with phototherapy has some of the highest clearance rates of any treatment.

Side Effects. All retinoids have the same potentially serious toxicities as do high doses of vitamin A. Side effects include:

Bone and joint pain
Bruising
Depression and possible suicide risk (with isotretinoin)
Eye problems, including blurred vision, cataracts, conjunctivitis, and a sudden deterioration in night vision
Fatigue
Headache
Increased bone growth, particularly in the ankles, pelvic area, and knees
Increased triglyceride levels
Liver damage
Nail problems
Skin and mucous membrane problems, including dry nose, nosebleeds, dry eyes, chapped lips, thinning hair, dry or "sticky" feeling skin, and peeling of the palms and soles

In rare cases, retinoids, particularly isotretinoin, may cause a condition called benign intracranial hypertension (pseudotumor cerebri), which occurs in the brain. Symptoms include headache, nausea, vomiting, and blurred vision. Patients experiencing these symptoms should call a doctor immediately and stop taking the drug.

Oral retinoids should not be taken during pregnancy.

Despite these side effects, oral retinoids remain among the safest systemic therapies for psoriasis. A low-fat diet, aerobic exercise, and fish oil supplements may help reduce the side effects. Certain cholesterol-lowering drugs, including gemfibrozil (Lopid) or certain statins, such as atorvastatin (Lipitor), may help control triglyceride levels.

Maintenance doses should be as low as possible and should be taken every second or third day.

Taking retinoids during pregnancy significantly increases the risk for severe birth defects in the unborn child. Pregnant or nursing women or those planning to become pregnant should not use these drugs. Women of childbearing age who take retinoids should have regular pregnancy tests.

Doctors recommend that acitretin should not be given to any woman who may become pregnant within 3 years of taking it. Drinking alcohol changes acitretin to a retinoid that is stored in fat cells for 3 years. It may have the potential for causing birth defects during that time. It's important to note that cooking products and over-the-counter preparations, such as cough syrup, may contain alcohol and be inadvertently consumed.
Women who are pregnant or plan to become pregnant should not use isotretinoin. As of December 31, 2005, everyone who takes, prescribes, or dispenses the drug must enroll in a national registry called iPLEDGE.

Cyclosporine (Neoral, Sandimmune, SangCya) blocks certain immune factors and may be effective for all forms of psoriasis. It is also a first line, or primary, systemic drug used to treat adults with severe psoriasis. Neoral is the preparation used most often for psoriasis and clears psoriasis in many patients within 8 - 12 weeks.

Side Effects. Cyclosporine has significant side effects if used for a long time, notably kidney problems and non-melanoma skin cancers. It should be reserved for patients who do not respond to phototherapy or less potent systemic medications (for example, methotrexate or acitretin).

Common and temporary side effects include:

Fatigue
Gingivitis
Gout
Hair growth
Headaches
Joint pain
Tremor

More serious complications may include:

Kidney damage
High blood pressure (Some doctors advise treating high blood pressure with calcium channel blockers, since other standard blood pressure drugs may worsen psoriasis. Calcium channel blockers also help prevent kidney problems.)
High cholesterol and lipid levels
High levels of calcium and low levels of magnesium
Increased risk for infections
Liver problems
Lymphomas
Skin cancers (Patients who have taken cyclosporine after PUVA therapy have a higher incidence of squamous cell skin cancer. According to a 2003 study, the risk is six times that of the general population. The risks are highest with long use and previous use of PUVA, methotrexate, or other immunosuppressants.)

To reduce complications of cyclosporine, the dosage is decreased after improvement occurs. Maintenance therapy is usually limited to a year, although some experts believe that a microemulsion form of Neoral (Neoral-Neo) may be safe for up to 2 years. Patients should be monitored regularly for high blood pressure and signs of kidney or liver problems and skin cancers.

Patients Who Should not Use Cyclosporine. Because the drug suppresses the immune system, people with active infections or cancer should avoid it. Patients with uncontrolled high blood pressure and impaired kidney function should also not use this medication. Cyclosporine therapy for children with psoriasis has not been well studied.

Drug and Food Interactions. Cyclosporine interacts with numerous drugs -- both prescription and over-the-counter preparations -- and also grapefruit and grapefruit juice.

Biological response modifiers, sometimes called "biologics," belong to a new class of drugs that are considered the most exciting development in psoriasis treatment. Biologics are genetically engineered drugs that interfere with specific components of the autoimmune response. Because of their precise targets, these drugs do not damage the entire immune system the way that general immunosuppressants do.

Biologics are considered second- or third-line treatments, and may be used alone or sometimes in combination with first-line systemic drugs.

There are different types of biologics used to treat psoriasis:

T cell blockers block immune cells linked to inflammation.
Tumor necrosis factor (TNF) blockers target the chemical messenger TNF-alpha, which is released during the inflammatory response.

Types of T-cell blockers:

Alefacept (Amevive). This drug is approved for the treatment of moderate-to-severe plaque psoriasis. Studies suggest that the drug produces 50 - 75% improvement in symptoms. Alefacept is given in a doctor's office or clinic. Patients receive weekly injections for 12 weeks. Patients need weekly blood tests to make sure T cell levels do not drop too low. Side effects are generally mild and include sore throat, dizziness, and cough. There have been a few reports of serious infection and cancer.
Efalizumab (Raptiva). This drug is approved for the treatment of moderate-to-severe plaque psoriasis. Many patients experience 50 - 75% improvement in symptoms within 4 - 6 weeks of starting the drug. Patients give themselves shots of this drug for 12 weeks. Some clinical trials suggest that a longer course of treatment (24 weeks) may also be safe and effective for patients with chronic plaque psoriasis. Some patients have flare-ups of psoriatic lesions after stopping efalizumab. Very serious, but rare, side effects include hemolytic anemia and antibiotic-resistant infections.

Types of TNF blockers:

Etanercept (Enbrel) is approved for the treatment of psoriatic arthritis and moderate-to-severe plaque psoriasis. The drug is given either alone or in combination with methotrexate. Side effects include infections and lymphoma, a type of cancer. Patients inject themselves under the skin, once or twice a week for 12 weeks. However, a 2007 study published in the Archives of Dermatology found that continuing etanercept after 12 weeks lowers the severity of disease without increasing infections or side effects. Study participants randomly received 50 milligrams of the drug or a placebo biweekly up to 84 weeks. Strongest improvements were noted at 48 weeks among those who received the drug.
Infliximab (Remicade) is approved for the treatment of psoriatic arthritis. Patients receive three intravenous infusions during the first 6 weeks of treatment. After the initial treatment period, patients receive an infusion every 8 weeks. Therapy takes 2 hours and is given in a doctor’s office or clinic. Patients with a history of infection or heart failure should not take this drug. Several studies have shown that symptoms improve significiantly by week 10 in the majority of patients with severe psoriasis who are treated with infliximab.
Adalimumab (Humira) is being tested in clinical trials for treatment of psoriasis and psoriatic arthritis. Results from a Phase III (late-stage) study show that the drug works better than methotrexate in the treatment of moderate-to-severe psoriasis.
Efalizumab (Raptiva) appears to effectively clear or nearly clear moderate-to-severe hand and foot psoriasis after 12 weeks. This type of psoriasis is often very difficult to control and treat.

Interleukins (IL) being investigated as sources or targets of therapy include IL-4, IL-2, IL-8, IL-11, and IL-12. For example, in a 2003 study, 75% of patients with severe psoriasis who were treated with interleukin-4 (rhuIL-4) experienced improvement rates of more than 68%.

A study of 180 patients with moderate-to-severe plaque psoriasis has shown that an investigational medicine called ABT-874 greatly reduced symptoms in most patients. ABT-874 targets proteins that are responsible for psoriasis-related inflammation.

Leflunomide. Leflunomide (Arava) is a disease-modifying antirheumatic drug (DMARD), which blocks autoimmune antibodies and is a powerful anti-inflammatory medication. It is proving to be active against psoriatic arthritis. Reports of adverse effects are comparable to those with methotrexate. Common problems include nausea, diarrhea, hair loss, and rash. Potentially serious side effects include infections and liver injury.

Sulfasalazine. Sulfasalazine (Azulfidine) is sometimes used for psoriasis. In one major analysis, sulfasalazine and methotrexate were the only medications proven to help patients with psoriatic arthritis. Many people, however, stop taking the drug because of common side effects that include headaches, gastrointestinal complaints, and rash. Benefits, if any, should be apparent in 4 - 6 weeks.

Immunosuppressants. Some immunosuppressants being studied for psoriasis include tacrolimus (Prograf), pimecrolium, and sirolimus. In one study, for example, tacrolimus showed an 83% reduction in symptoms in patients with psoriasis who used the drug. Studies have been limited, however. Side effects of these medications are similar to those of cyclosporine. Pimecrolimus may specifically target the skin and so have fewer side effects. (Some are also being studied as topical treatments.)

Phototherapy

Phototherapy means to treat with light.

When sunlight penetrates the top layers of the skin, this ultraviolet radiation bombards the DNA inside skin cells and injures it. This can cause wrinkles, aging skin, and skin cancers. However, these same damaging effects can destroy the skin cells that form psoriasis patches.

Phototherapy for psoriasis can be given as ultraviolet A (UVA) light in combination with medications, or as variations of ultraviolet B (UVB) light with or without medications. Not everyone is a candidate. For example, it may not be appropriate for patients who should avoid sunlight or those with very severe psoriasis.

Ultraviolet A (UVA) is a main part of sunlight. UVA phototherapy uses a photosensitizing medication (usually psoralen) in combination with UVA radiation to be effective. A photosensitizing medication makes a person more sensitive to light. Treatment with psoralen and UVA is referred to as PUVA. This approach is very powerful and effective in more than 85% of patients who use it. However, it poses a higher risk for skin cancers than UVB.

PUVA treatments cause inflammation and redness in the skin to develop within 2 - 3 days after treatment. Such damage inhibits skin cell proliferation and reduces psoriasis plaque formation.

Forms of psoralen include methoxsalen, 8-methoxypsoralen (8-MOP), or bergapten (5-MOP). The effectiveness of the treatment is based on a chemical reaction in the skin between the psoralen and light, which creates redness and inflammation that prevents the psoriasis disease process.

People should avoid this treatment if they are taking drugs or have conditions that cause them to be light sensitive. They should also take protective measures before, during, and after each treatment.

Initial PUVA Treatment Phase. The initial phase typically follows these steps:

Psoralen is typically taken by mouth in the form of 8-methoxypsoralen (for example, Oxsoralen) 75 minutes to 2 hours before the treatment starts. Psoralen reaches the skin through the bloodstream, where it increases the skin's sensitivity to UVA radiation.
Topical preparations of psoralen are alternatives to pills. They can be "painted on" or applied to the affected areas by soaking or bathing in a psoralen solution. PUVA-bath therapy may be especially useful for persistent psoriasis on the palms and soles or for patients with liver disease or who get severe nausea from taking the pill form. UVA should be given within 15 minutes of using topical psoralen.
The patient enters and stands in a light box, a unit lined with ultraviolet lamps. The initial UVA exposure time is very short (seconds to several minutes), and then increases to 20 minutes or longer. The amount of time a person is exposed to UVA rays depends on the skin type, with the shortest times recommended for fair-skinned patients.
Treatments may be repeated two or three times a week. They should never be performed more frequently than once every other day, since the full effects of the treatments are not evident for 48 hours.

It takes an average of about 25 PUVA treatments for full effect, but during that period, treatment intensity may vary.

If there is no response after 10 treatments, the doctor may increase the UVA energy.
If there is still no response after 15 treatments, the psoralen dosage may be increased.
If a patient's skin does not improve at all or worsens after these changes, the treatment is temporarily stopped. PUVA may be causing a toxic response in such cases, and, often, the condition gradually improves over the following 2 weeks.
If the skin does not improve over the following 2 weeks, PUVA treatment has failed. If skin improves during this resting period, treatment resumes.

Maintenance Phase. Once the psoriasis has improved by about 95%, the patient may be put on a maintenance schedule. Often only one or two treatments a month are needed, but some people may need more frequent treatments. As maintenance continues and the interval between treatments lengthens, the patients may become more susceptible to tanning and sunburn. They should reduce exposure to natural sunlight during this time.

Success Rates. Nearly 90% of patients achieve marked improvement or clearing within 20 - 30 treatment sessions.

Combinations. Combining acitretin, calcipotriene, methotrexate, or tazarotene gel with PUVA may enhance effectiveness or increase response. In addition, combinations may allow for lower doses of radiation or medications to be used, minimizing side effects. Retinoids may also help protect against skin cancers, while methotrexate may increase the risk. In some cases, patients resistant to PUVA or UVB may respond when the phototherapies are combined.

Side Effects and Complications of PUVA.

The psoralen methoxsalen causes a general ill-feeling and nausea in 20% of patients. Dividing up the dose and taking it in 15-minute intervals with food, or taking ginger 20 minutes before taking the drug, may be helpful.
Skin reactions, including itching, sunburn, and blistering, are common. These can generally be avoided with careful administration of PUVA therapy and protective measures. Antihistamines, baths with special oatmeal preparations (Aveeno), and capsaicin ointment (Zostrix) may be helpful.
After treatment, white spots commonly develop where psoriasis plaques had been, particularly in people with naturally darker skin. If they are troublesome, tanning products may help darken them. Small, dark raised spots called PUVA lentigines may also develop in affected areas with long-term treatment
Prolonged standing may trigger fainting in people with certain heart or blood pressure problems.
People with liver disease should discuss using topical psoralens, since oral forms may have adverse effects on the liver.
UVA penetrates the skin more deeply than UVB, so there is a greater danger of deep skin damage, accelerated skin aging, and skin cancers. Anyone who needs to avoid sunlight should not get this treatment.
The procedure increases the risk for cataracts if eyes are not protected for up to 24 hours after treatment.

Special Warning on PUVA and Skin Cancers. It has been known for some time that PUVA can change DNA and cause genetic mutations. PUVA is known to increase the risk for squamous cell skin cancer and slightly increase the risk for basal cell skin cancer, both of which are nearly always curable. One study reported an increased risk of melanoma. The risk for skin cancers is higher in persons who have:

A family or personal history of skin cancer
Light skin and fair or red hair
Received radiation or x-ray treatments or taken immunosuppressant drugs
Received over 200 PUVA treatments

Discussions are under way about discontinuing PUVA for psoriasis. The arguments generally are as follows:

Opponents of PUVA argue that studies suggest a long-term risk for melanoma, starting about 15 years after treatment, particularly in people who receive more than 250 treatments. In one long-term study, only 9 out of 1,380 patients developed melanoma. However, 7 of these cases occurred in the last 5 years of the study, indicating that the danger persists and more patients in this study are likely to develop this serious skin cancer as time goes on.
Supporters of PUVA argue that it is not yet known if the people who developed melanoma experienced sunburn during the procedures or if they already had risk factors for skin cancers. If so, then properly given treatments could still be considered safe for patients without risk factors. They also argue that PUVA is still the most effective treatment for severe psoriasis, and the alternatives are usually very powerful and relatively new drugs that may have even more serious side effects. Furthermore, the addition of retinoids may protect against skin cancers while proving to be a very effective combination.

Side effects of UVA radiation can be severe. Protective measures are needed during, before, and after treatment. Patients should avoid prolonged exposure to the sun for 24 hours before the oral treatment starts.

Protective Measures During Treatment:

Patients should wear specially designed goggles to protect the eyes from UVA radiation.
Sensitive areas, such as genitals, abdominal skin, and breasts, should be covered until tanning occurs in the exposed areas, after about a third of the treatment period. Note that PUVA is associated with a high risk for genital skin cancers, so male genitals must be covered throughout the process.

The following safety features should be available in the PUVA chamber:

Lamps with protective shields
A viewing window for a health professional to check the patient periodically
A door that can be opened by the patient easily and with little pressure
A timer that terminates the session automatically
An accessible alarm device

Protective Measures After Treatment. The drugs used in PUVA increase susceptibility for a natural sunburn for hours after treatment. The patient should take the following precautions:

Patients should wear UVA absorbing wrap-around sunglasses that are designed to completely block out stray radiation. They should begin wearing them as soon as they take the drug, and for at least 12 hours after the treatment. This is important to prevent a PUVA reaction around the eyes that can cause cataracts. There is no need to wear these glasses after sundown.
For about 8 hours after taking the drug, patients must also avoid exposure to daylight, even if the day is cloudy or exposure occurs through windows.
Patients who must go out should wear heavy opaque clothing (clothes that do not let light through), including hats and gloves.
Patients should apply sunblock over all exposed areas, including the lips. The sunblock should have an SPF (sun protection factor) of more than 15 and include ingredients that block both UVB and UVA radiation.
No patient should spend a long time in sunlight for at least 2 days after the combined treatment.

Ultraviolet B is another main part of sunlight, and is the main cause of sunburn. It generally affects the outer skin layers. UVB radiation reduces the abnormally rapid skin cell growth that occurs with psoriasis.

Types of UVB therapy:

Broadband UVB
Narrowband UVB (NB-UVB)
Laser treatments

Broad spectrum or broad band UVB is radiation in the wavelength of 290 - 350 nanometers, and is the standard UVB phototherapy treatment in the United States. It is not as potent as the treatments that use narrow-band UVB or PUVA, and is not useful for chronic psoriasis.

Broadband UVB may be given with or without medications. When used without medication (known as selective ultraviolet phototherapy), UVB treatment generally is given as follows:

Treatment starts in the doctor's office or another medical setting. Once the disease has stabilized, the patient can obtain a prescription for equipment that can be used at home. Even at home, treatment must always be supervised.
In preparation, the patient fully undresses, although unaffected areas may be covered to avoid overexposure.
The initial session may last as little as a few seconds, depending on whether the patient has a lighter or darker skin, with the lightest skin exposed to the briefest session. The duration increases with each treatment until the skin clears or the patient experiences itching or irritation. It should be noted that the condition may worsen initially.
UVB therapy usually requires about 20 - 40 treatments (about three per week). Full results take about 3 weeks.

Use of Medication. UVB was commonly used with coal tar (the Goeckerman regimen) in past decades, and then with anthralin (the Ingram regimen). Other medications are being studied with some success, and may prove to be tolerated better.

The Goeckerman regimen requires daily treatments for up to 4 weeks. The coal tar or anthralin are applied once or twice each day and then washed off before the procedure. Studies indicate that a low-dose (1%) coal tar preparation is as effective as high dose (6%). Such regimens are unpleasant, but still useful for some patients with severe psoriasis, since they can achieve long-term remission (up to 6 - 12 months).

Some evidence suggests that using a simple emollient (such as Vaseline or mineral oil) that enhances UVB light penetration can be effective. This addition to the treatment increases the risk for sunburns, however, and patients must be careful to avoid sun exposure. Researchers are tring combinations of other topical and oral medications. For example, combining UVB with methotrexate, or retinoids such as a tazarotene gel or oral acitretin, is producing positive results. Combinations with any of these drugs, however, must be supervised carefully to avoid serious reactions.

Side Effects of UVB. The treatment can cause itching and redness. UVB radiation from sunlight is known to increase the risk for skin cancers. There is no strong evidence, however, that UVB treatments pose any risk for skin cancers except on male genitalia. This risk, however, can be significant (4.5%) at high doses.

Narrow band radiation may be safer than other approaches, and some experts now believe it should be the first option for patients with chronic plaque psoriasis.

NB-UVB is used without medications and is very strong. Whether it has any affect, however, on the disease process itself is unclear. The light wavelength is between 310 - 312 nanometers, which, theoretically, is the most beneficial part of sunlight.

Exposure times are shorter but of higher intensity than with broadband UVB. This therapy is probably less likely than PUVA to cause skin cancers.

Clearance of 75% typically occurs after 10 - 12 treatments. NB-UVB treatments performed three times a week achieve results that are equal to twice-weekly PUVA treatments. Weekly NB-UVB treatments are not effective. Studies so far are mixed on whether NB-UVB remission rates are equal to those of PUVA.

Patients prefer NB-UVB over other PUVA treatments because they do not have to wear protective eyewear, take medications, or experience unpleasant side effects, notably nausea. It is also safe for pregnant women and children.

Combinations with topical medications, such as tazarotene or psoralens, may help NB-UVB therapy work better.

Laser UVB Treatment. A recent variation of a device called an excimer laser (Xtrac) delivers a precise UVB wavelength of 308 nanometers. The laser is more effective than narrow-band UVB for localized psoriasis, since it allows very specific areas of skin to be targeted. (Note: The therapy is not suitable for the scalp.) Generally, 8 - 10 treatments given twice a week will clear psoriasis. Remission rates are similar to NB-UVB, but the excimer laser can clear the psoriasis faster and at lower doses. It also spares the healthy skin around it. Blistering is a common side effect. More comparison studies are needed to determine risk and benefits compared to NB-UVB, particularly any long-term risk for skin cancer.

Pulsed-Dye Lasers. Pulsed-dye lasers give off high-intensity yellow light, which destroys the tiny blood vessels that make up psoriatic plaques. This treatment has been used for years to remove birthmarks, such as port wine stains and unsightly blood vessels on the skin. Some studies have reported significant (but not complete) improvement, and remissions that have lasted up to 13 months. Treatment sessions last up to 30 minutes and can feel uncomfortable (similar to being repeatedly snapped with a rubber band). It typically takes up to six sessions to clear the target areas. Bruising is common, and there is a small risk for scarring.

Home tanning devices and tanning salons are not usually recommended, but they may be helpful for patients without access to a medical unit. In a 2003 study, many patients achieved a significant reduction in symptoms when taking acitretin and exposed to a UVB commercial tanning unit (specifically, a Wolff tanning bed).

However, UV outputs can vary widely among tanning beds and salons. Some units emit UVA radiation, which poses a higher risk for skin cancers. Adverse effects of tanning salons that use UVA or UVB radiation are the same as with any UV phototherapies, including a risk for skin cancer.

Managing Psoriasis

Although sunburn carries a risk for skin cancer and can make psoriasis worse, regular exposure to the sun helps clear psoriasis in people with mild-to-moderate conditions. People should cover non-affected areas with clothing or sunscreen and sun bath only until the skin starts to tan.

Vacations in sunny areas, such as Hawaii or the Caribbean, can offer relief. For those who can afford it, a prolonged stay of several weeks at the Dead Sea in Israel has proven to significantly improve or clear 88% of those with psoriasis who go there. The region offers a unique combination of intense but naturally filtered UVA radiation combined with minerals and salts from the sea.

Because of the association between negative emotions and psoriatic flare-ups, relaxation and anti-stress techniques may be helpful. A small 1999 study found that hypnosis aimed at reducing stress may relieve symptoms.

Another study found that some patients with psoriasis had a traumatic or stressful event coincide with the appearance of psoriasis. Talking to a psychiatrist about the issue resulted in significant symptom improvement in 62% of study patients who recalled such an event.

If skin becomes dry and itchy, the patient may try the following:

Soak in a warm bath for about 15 minutes.
Afterward, apply salicylic acid first, which removes scaly skin and may promote the penetration of both moisturizers and topical prescription medications.
Then, apply a thick moisturizer or emollient, such as Vaseline, Cetaphil cream, or Eucerin cream. Lotions are not good enough moisturizers.
Special gloves made of Gore-Tex (DermaPore) may be worn at night over a thick moisturizer cream. These gloves are protective but also allow moisture to escape.

Some experts suggest that many common moisturizers may actually increase water loss in psoriasis, but studies still have to confirm this. In the meantime, if moisturizers help relieve the condition, patients should use them.

Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. It is used to relieve arthritic pain and may help relieve psoriatic itching. Capsaicin should be handled using a glove and applied to affected areas three or four times daily. The patient will usually have a burning sensation when the drug is first applied, but this sensation lessens with use.

Folic Acid. Patients should be sure they get enough of the B vitamin folate (folic acid). Folate-rich foods include liver, asparagus, fruits, green leafy vegetables, dried beans and peas, orange juice, and yeast. Many types of bread and other commercial grain products now have added folic acid.

Omega-3 Fatty Acids. Omega-3 fatty acids, particularly those found in some fish oil, have anti-inflammatory properties that may benefit some patients with psoriasis and other autoimmune conditions.

Patients with persistent psoriasis may be tempted to try alternative or untested treatments, including herbs and other nontraditional therapies. Researchers at the Medical College of Georgia say green tea slowed the growth of skin cells in animal studies and may one day prove to be useful in treating psoriasis. More research is needed.

Several traditional remedies for psoriasis include various other herbal supplements, but to date no clinical studies have been reported on these substances. No one should use any unproven therapy without consulting a doctor to be sure such treatment is not harmful, and does not interfere with any standard medications they take.

Herbal remedies and dietary supplements are not regulated by the FDA. This means that manufacturers and distributors do not need FDA approval to sell their products. In addition, any substance that affects the body's chemistry can, like any drug, produce side effects that may be harmful. There have been many reported cases of serious and even deadly side effects from herbal products.

The following are special concerns for people taking natural remedies for psoriasis:

Zinc pyrithione is sometimes used, but its effectiveness is doubtful. A number of so-called natural psoriasis products (Skin-Cap, Blue Cap, Miralex) that contain this compound also contain prescription-strength corticosteroids. Such steroids have the same side effects as those in standard psoriasis agents. These products have been banned in the U.S. and Canada, but similar untested medications are available over the Internet.
Gotu Kola (Centella asiatica) is sometimes applied in a cream for psoriasis. The oral form of the herb has serious side effects, however, including increasing the risk for miscarriage in pregnant women.

Outlook

Psoriasis is lifelong and not curable. Although it is also marked by rapid cell growth, psoriasis is neither cancerous nor contagious.

In general, studies report the following features of its course:

The condition almost always relapses. In a few cases, large areas of plaque can persist for years.
Psoriasis nearly always goes into remission, however, often clearing on its own. In one study, 30% of patients reported untreated psoriasis going into remissions that lasted 1 - 54 years.
Psoriasis can improve during pregnancy, especially during the second and third months. Increased levels of estrogen may be responsible for this improvement. Relapse may occur after giving birth.

The emotional and social consequences of psoriasis should not be underestimated.

Many patients suffer severe humiliation and depression if plaques are visible. Some even withdraw from society and become isolated.
Some patients are forced to leave their jobs and go on disability if the condition becomes incapacitating.

Researchers have reported the following:

Surveys of patients with psoriasis report a negative mental and physical impact that is nearly equivalent to that of other major chronic conditions, including cancer, high blood pressure, diabetes, heart disease, and depression.
In one study, 75% of patients reported that psoriasis hurt their confidence.
Another study reported that 8% of people with psoriasis felt their life was not worth living.

Some patients, particularly men, use alcohol and smoking as self-medication to reduce the emotional consequences of psoriasis. In fact, studies have found that people with psoriasis have higher mortality rates, mostly from heavy drinking. Smoking has also been cited as a major risk, particularly for pustular psoriasis. Some experts believe that drinking and smoking may actually cause biological damage that contributes to psoriasis itself.

However, smoking may delay the onset of psoriatic arthritis in some patients, depending on when they started the habit. Psoriatic arthritis tends to occur about a decade after psoriasis develops. The review of 281 psoriasis patients showed that the condition appeared after about 13 years in nonsmokers, compared to 23 years in those who began smoking after the first onset of psoriasis. Psoriatic arthritis appeared after 8 years in people who smoked before developing psoriasis.

Folate Deficiency in Severe Psoriasis. Severe psoriasis can also cause folate deficiency. Folate is a B vitamin that is important for nerve function, preventing birth defects. It also prevents elevations of homocysteine, a factor that may play a critical role in heart disease.

Skin Cancers. In one study, patients with severe psoriasis (who receive medications that affect the whole body) were at higher than normal risk for developing cancers, primarily skin cancers and lymphomas. The risk was not any higher for patients with milder psoriasis. There is some indication, however, that patients with psoriasis have a higher risk for non-melanoma skin cancers regardless of treatments.

Heart Attacks. A study released in October 2006 shows an increased risk of heart attacks in people with psoriasis. The risk was highest in young patients with severe psoriasis.

Other Coexisting Conditions: Studies done in Newfoundland and Germany have also revealed increased cases of diabetes, obesity, arthritis, and cancer in patients with psoriasis. Research is underway to determine if there are genetic links between psoriasis and these conditions.

Increased Risk of Death. Severe psoriasis has been linked to a significant increase in a patient's risk of death. A study of more than 713,000 patients showed that severe psoriasis increased mortality by 50%. Study authors encourage patients to receive comprehensive health examinations to reduce the risk. Study participants were considered to have severe psoriasis if they required systemic treatment.

Impaired Temperature Regulation. Erythrodermic psoriasis, in which psoriasis covers the entire skin, can cause abnormalities in the body's ability to regulate temperature.

Zumbusch Psoriasis. A combination of erythrodermic and pustular psoriasis causes a serious condition called Zumbusch psoriasis:

The condition can develop abruptly.
Symptoms may include fever, chills, weight loss, and muscle weakness.
Patients may develop excessive fluid build-up, protein loss, and electrolyte imbalances. In such cases, hospitalization is required. Fluid and chemical balances must be restored and temperature stabilized as soon as possible.

Zumbusch psoriasis can be life threatening, particularly in the elderly. The condition is very rare in children and, if it occurs, tends to improve more quickly than in adults, possibly even without medication.

Most cases of psoriatic arthritis (PsA) are mild, but complications can occur:

Severe joint deformity and destruction (called arthritis mutilans) may develop, generally in the small joints of the hands and feet. Studies report this happens in about 5 - 16% of patients. Psoriasis patients with other arthritic conditions (osteoarthritis or rheumatoid arthritis) in the joints of the fingers tend to have a higher risk.
People with PsA may have a higher risk for respiratory illnesses.

Some earlier studies indicated that patients with psoriatic arthritis had a shorter lifespan than the general population, but more recent studies found no significant difference.

Resources

www.psoriasis.org -- National Psoriasis Foundation
www.aad.org -- American Academy of Dermatology
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.clinicaltrials.gov -- Find clinical trials

References

Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006 Oct 11;296(14):1735-41.

U.S. Food and Drug Administration. CDER Drug and Biologic Approvals for Calendar Year 2006 -- Updated through August 31, 2006. Last accessed on 15 October, 2006.

FDA Announces Strengthened Risk Management Program to Enhance Safe Use of Isotretinoin (Accutane) for Treating Severe Acne. US Food and Drug Administration. Rockville, MD: National Press Office; August 12, 2005.

Anstey AV and Kragballe K. Retrospective assessment of PASI 50 and PASI 75 attainment with a calcipotriol/betamethasone dipropionate ointment. Int J Dermatol. 2006 Aug;45(:970-5.

National Psoriasis Foundation. About Psoriasis: Statistics. Last Accessed 9 October, 2006.

Antoni CE, Kavanaugh A, Kirkham B, Tutuncu Z, Burmester GR, Schneider U. Sustained benefits of infliximab therapy for dermatologic and articular manifestations of psoriatic arthritis: results from the infliximab multinational psoriatic arthritis controlled trial (IMPACT). Arthritis Rheum. 2005;52(4):1227-1236.

Bowcock AM, Cookson WO. The genetics of psoriasis, psoriatic arthritis and atopic dermatitis. Human Mol Genet. 2004;13 Spec No 1:R43-55.

Feldman SR, Koo JY, Menter A, Bagel J. Decision points for the initiation of systemic treatment for psoriasis. J Am Acad Dermatol. 2005;53(1):101-107.

Murase JE, Chan KK, Garite TJ, Cooper DM, Weinstein GD. Hormonal effect on psoriasis in pregnancy and post partum. Arch Dermatol. 2005;141(5):601-6.

Review Date:
9/19/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

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