FitSugar

Minutes to a Healthier You: Posture Check

FitSugar — Mon, 22 Sep 2008 08:00:00 -0700

It's not the hours we spend at the gym that make a difference in our health, it's the little things too. Like paying attention to how you stand. Your posture affects every activity you do from cooking dinner to running on the treadmill. Take advantage of the moments throughout your day when you can to do a postural check-in: riding the elevator up to the office, standing in line at the ATM, washing the dishes, waiting for a traffic light to change to green. You catch my drift. Every time you are just standing around make sure: your pelvis is over your ankles, that your ribs are over your pelvis, your shoulders over your ribs and your head floating up above it all. Also make sure you have your weight evenly distributed on both feet. When I am standing still, I often find my glutes clenched, pelvis tucked under, and my ribs tilted back with my shoulders far behind my pelvis. Plus I tend to stand with most of my weight on my left foot. Needless to say, when I align my body and put some weight on my right foot, my back stops aching. Check your posture next time you are just standing there and see how you really stand.

Need some more pointers on how to improve your posture? Then check out - Attention: Stand Up Straight. And if you would like more tips on staying healthy during your busy days read all my Minutes to a Healthier You ideas.

Source

Work it Girl: Chair Spinal Twist

FitSugar — Fri, 13 Apr 2007 12:30:00 -0700

Take a break from working already! I love doing a spinal twist at my desk because it really loosens up my lower back and gives my eyes a rest. I try to do this every half hour or so.

Push your chair slightly away from your desk and then sit down gazing forward.

Bend your left knee and plant your foot on your chair - slip your shoes off if you're wearing heels.

Reach your right arm up and cross your elbow over the outside of your left knee. You can increase the intensity of the twist by pulling with your hands and putting weight into your left foot.

Stay here for a few breaths or as long as you want. Then slowly release your torso back to center and place your left foot on the ground. Don't forget to do the other side!

Twisting is so important for the health of our spines. This feels good and is so good for you. Try it right now and let me know what you think.

Scoliosis

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

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Diagnosing Scoliosis

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

Defining Scoliosis

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

Causes

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

Treatment with Bracing

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

Introduction

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

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

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

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

Click the icon to see an image of scoliosis.

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

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

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

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

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

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

Click the icon to see an image of kyphosis.

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

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

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

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

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

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

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

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

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

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

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

Click the icon to see an image of the spine.

Click the icon to see an image of the sacrum.

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

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

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

Causes

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

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

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

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

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

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

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

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

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

Adult scoliosis has two primary causes:

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

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

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

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

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

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

Risk Factors

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

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

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

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

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

Prognosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Symptoms

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

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

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

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

Diagnosis

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

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

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

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

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

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

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

Other Physical Tests.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Managing Scoliosis

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

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

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

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

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

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

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

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

Braces

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Surgery

The goals of scoliosis surgery are threefold:

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

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

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

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

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

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

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

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

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

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

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

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

In the fusion procedure, the surgeon will:

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

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

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

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

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

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

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

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

Certain complications may occur from this procedure:

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

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

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

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

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

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

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

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

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

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

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

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

The anterior approach also has its advantages and disadvantages:

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

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

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

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

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

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

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

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

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

Newer endoscopic techniques are reducing the need for transfusions.

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

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

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

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

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

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

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

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

Click the icon to see an image of gallstones.

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

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

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

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

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

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

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

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

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

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

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

Treatment for Adult Scoliosis

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

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

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

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

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

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

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

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

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

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

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

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

Resources

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

References

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

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

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

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

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

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

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

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

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

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

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

A.D.A.M. Copyright

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

adam.com

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 ).

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. Copyright

adam.com

Osteoporosis

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

In This Report

Highlights
Introduction
Causes
Symptoms
Fractures
Risk Factors
Diagnosis
Lifestyle Changes
Medications
Treatment
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approvals

In 2007, the Food and Drug Administration (FDA) approved zoledronic acid (Reclast) for postmenopausal osteoporosis treatment. Zoledronic acid is given as an injection once a year. A 2007 study in the New England Journal of Medicine indicated that zoledronic acid can significantly reduce the risk of spine, hip, and other fractures.
In 2007, the FDA approved raloxifene (Evista) for prevention of breast cancer in postmenopausal women with osteoporosis and postmenopausal women at high risk for breast cancer. Raloxifene was previously approved for prevention and treatment of osteoporosis.

Calcium and Vitamin D for Osteoporosis Prevention

In 2007, the Food and Drug Administration proposed allowing manufacturers of food and supplements to put a health claim on their products stating that the combination of calcium and vitamin D can reduce the risk of osteoporosis.
In 2007, the National Osteoporosis Foundation updated its daily intake guidelines to recommend 1,200 mg of calcium, and 800 - 1,000 IU of vitamin D3, for adults age 50 and older.
Calcium plus vitamin D is effective in preventing osteoporosis in people age 50 years and older, according to a 2007 review in the Lancet. The researchers found that a minimum of 1,200 mg of calcium and at least 800 IU of vitamin D per day gave the most protection.

Fosamax: Taking a Break (Without Breaking a Bone)

Women at low risk for fracture may be able to temporarily stop taking alendronate (Fosamax) after 5 years, suggests a 2006 study in the Journal of the American Medical Association.

Antidepressants and Osteoporosis Risk

Selective serotonin reuptake inhibitors (SSRIs), the most commonly used class of antidepressants, may increase the risk for bone loss in both older men and women, according to several studies published in 2007 in the Archives of Internal Medicine. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). The researchers did not find that other types of antidepressants are associated with reduced bone mineral density.

Introduction

Osteoporosis is a disease of the skeleton in which bones become brittle and prone to fracture. In other words, the bone loses density. Osteoporosis is diagnosed when bone density has decreased to the point where fractures occur with mild stress.

The skeleton consists of groups of bones which protect and move the body.

Until a healthy person is around age 40, the process of breaking down and building up bone by cells called osteoclasts and osteoblasts is a nearly perfectly coupled system, with one phase stimulating the other. As a person ages, or in the presence of certain conditions, this system breaks down and the two processes become out of sync. The reasons why this occurs during aging are not clear. Some individuals have a very high turnover rate of bone, some have a very gradual turnover, but the breakdown of bone eventually overtakes the build-up.

The Function of Bones. The skeleton has a dual function:

It provides structural support for muscles and organs.
It also serves as a depot for the body’s calcium and other essential minerals, such as phosphorus and magnesium.

The skeleton holds 99% of the body’s calcium. The remaining 1% circulates in the blood and is essential for crucial bodily functions, ranging from muscle contraction to nerve function to blood clotting.

Bone Turnover: the Breakdown and Growth of Bones. Like other organs in the body, bone tissue is constantly being broken down and reformed again. This turnover is necessary for growth, for repair of minor damage that occurs from everyday stress, and for the maintenance of a properly functioning body. Two essential cells are involved in this process:

Osteoblast cells are produced by bone cells and are the bone builders. They rebuild the skeleton, first by filling in the holes with collagen, and then by laying down crystals of calcium and phosphorus.
Osteoclast cells are formed from certain blood cells and are responsible for the breakdown, or resorption, of the skeleton. These cells dig holes into the bone and release the small amounts of calcium into the bloodstream that are necessary for other vital functions.

Each year, about 10 - 30% of the adult skeleton is remodeled in this way. The bone build up (formation)-break down (resorption) balance is controlled by a complex mix of hormones and chemical factors. If bone resorption occurs at a greater rate than bone build up, your bone loses density and puts you at risk for osteoporosis.

In women, estrogen loss after menopause is associated with rapid resorption and loss of bone density. This group, then, is at highest risk for osteoporosis and therefore for fracture.

There are two primary kinds of osteoporosis: type I and type II:

Type I. Type I, or high turnover, osteoporosis occurs in 5 - 20% of women, most often between the ages of 50 and 75. This is because of the sudden postmenopausal decrease in estrogen levels, which results in a rapid depletion of calcium from the skeleton. This is associated with fractures that occur when the vertebrae compress together, causing a collapse of the spine. It is also associated with fractures of the hip, wrist, or forearm caused by falls or minor accidents. Women have a higher risk for type 1 osteoporosis than men.
Type II. Type II, or low turnover, osteoporosis (also known as age-related or senile osteoporosis) results when the process of resorption and formation of bone are no longer coordinated, and bone breakdown overcomes bone building. (This occurs with age in everyone to some degree.) Type II osteoporosis affects both men and women and is primarily associated with leg and spinal fractures. Older women can have both type I and type II osteoporosis.

Click the icon to see an image of a compression fracture.

What determines the existence of osteoporosis, whether type I or type II, is the amount of calcium left in the skeleton and whether it places a person at risk for fracture. Someone who has exceptionally dense bones to begin with will probably never lose enough calcium to reach the point where osteoporosis occurs, whereas a person who has low bone density could easily develop osteoporosis despite losing only a relatively small amount of calcium.

Secondary osteoporosis is caused by other conditions, such as hormonal imbalances, diseases, or medications (such as corticosteroids or anti-seizure drugs).

Click the icon to see an image of osteoporosis.

Causes

Because the patterns of reforming and resorbing bone often vary from patient to patient, experts believe several different factors account for this problem. Important chemicals (such as estrogen, parathyroid hormone, and vitamin D) and blood factors that affect cell growth are involved with this process. Changes in levels of any of these factors could play a role in the development of osteoporosis.

Although ordinarily associated with women, sex hormones play a role in osteoporosis in both genders, most likely by controlling the birth and duration of life of both osteoclasts (bone breakers) and osteoblasts (bone builders).

Women and Estrogen. Experts are still puzzled by the rapid decline in bone density after menopause, when a woman’s ovaries stop producing estrogen. Estrogen comes in several forms:

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

The most potent form of estrogen is estradiol. Estradiol deficiency appears to be a very strong factor in the development of osteoporosis.
The other important but less powerful estrogens are estrone and estriol.

The ovaries produce most of the estrogen in the body, but it can also be formed in other tissues, such as body fat, skin, and muscle. After menopause, some amounts of estrogen continue to be manufactured in the peripheral body fat. Even though the ovaries have stopped producing estrogens directly, they continue to be a source of the male hormone testosterone, which converts into estradiol.

Estrogen may have an impact on bone density in various ways:

Estrogen’s most important effect on osteoporosis appears to be prevention of bone breakdown (resorption). Some research suggests that estrogen may control the life span of osteoclasts, the cells responsible for bone breakdown.
One study reported that part of estrogen’s beneficial actions may involve maintaining normal levels of vitamin D, an important nutrient in bone protection.

Men and Androgens and Estrogen. In men, the most important androgen (male hormone) is testosterone, which is produced in the testes. Other androgens are produced in the adrenal glands. Androgens are converted to estrogen in various parts of a man’s body, including bone.

Click the icon to see an image of the adrenal glands.

Studies have suggested that the loss of estrogen as well as testosterone may contribute to bone loss in elderly men. In one study, elderly men were first given a drug that blocked their normal hormones and then were given estrogen and testosterone patches. When the estrogen patch was removed, the bone breakdown process accelerated. When both patches were removed, the number of the bone-building cells (the osteoblasts) decreased. In other words, both hormones appeared to be integral to bone function in men.

Low levels of vitamin D and high levels of parathyroid hormone (PTH) are associated with hip fracture in women after menopause:

Vitamin D is a vitamin with hormone-like properties. It is essential for the absorption of calcium into the bone and for normal bone growth. Lower levels result in impaired calcium absorption, which in turn causes an increase in PTH.
Parathyroid hormone (PTH) is produced by the parathyroid glands. These are four small glands located on the surface of the thyroid gland. They are the most important regulators of calcium levels in the blood. When calcium levels are low, the glands secrete more PTH, which then increases blood calcium levels. High persistent levels of PTH stimulate bone resorption (bone loss).

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

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

Click the icon to see an image of the parathyroid glands.

Several studies on family members, including twins, have strongly suggested that genetic factors help determine bone density. Some examples include the following:

Of particular interest are genetic factors that affect vitamin D, a critical nutrient for calcium absorption in the body.
Many studies are looking at abnormalities in genes that may cause deficiencies in estrogen receptors, molecules that help estrogen work on cells. Estrogen is important in maintaining bone density in both men and women.

Corticosteroids. More than 30 million Americans have disorders that are commonly treated using corticosteroid drugs (also called glucocorticoids or steroids). Oral corticosteroids can reduce bone mass in both men and women. It is not clear whether inhaled steroids carry the same risks, but some studies indicate that they may cause bone loss when taken at higher doses for long periods of time. (Children on inhaled steroids may have temporary impaired growth, but they do not appear to be at risk for bone loss.)

Antidepressants. Selective serotonin reuptake inhibitors (SSRIs) -- a class of antidepressants that includes fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) -- may be associated with bone loss in both older men and women, according to two 2007 studies in the Archives of Internal Medicine. The researchers did not find an increased risk for bone loss with other types of antidepressants.

Diuretics. Diuretics, which are used to treat high blood pressure, have different effects on osteoporosis, depending on the type. Loop diuretics, such as furosemide (Lasix), increase the kidneys’ excretion of calcium, which can lead to thinning bones. Thiazide diuretics, on the other hand, protect against bone loss, but this protective effect ends after use is discontinued.

Contraceptives. Hormonal contraceptives that use progestin without estrogen (such as Depo-Provera injection or other progestin-based contraceptives), can cause loss of bone density. For this reason, the Food and Drug Administration (FDA) recommends that Depo-Provera injections should not be used for longer than 2 years. Some, but not all, studies suggest that combination estrogen-progestin oral contraceptives increase the risk for osteoporosis later in life. Women who take birth control pills should be sure to get adequate calcium and vitamin D from diet or supplements.

Other Medications. Anti-epileptic (anti-seizure) drugs increase the risk for bone loss (as does epilepsy itself). Other drugs that increase the risk for bone loss include the blood-thinning drug heparin, and hormonal drugs that suppress estrogen (such as gonadotropin-releasing hormone agonists). A 2006 study in the Journal of the American Medical Association suggested that long-term (greater than 1 year) use of proton-pump inhibitors (PPIs) may increase the risk for hip fractures. PPIs are used to treat gastroesophageal reflux disease (heartburn) and include omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium).

Predisposing Medical Conditions. Osteoporosis can be secondary to several other conditions, including alcoholism, diabetes, hyperthyroidism, epilepsy, chronic liver or kidney disease, celiac disease, scurvy, rheumatoid arthritis, leukemia, cirrhosis, gastrointestinal diseases, vitamin D deficiency, hypogonadism (impaired development of reproductive organs), lymphoma, hyperparathyroidism, and rare genetic disorders such as Marfan and Ehlers-Danlos syndrome.

Symptoms

Many people confuse osteoporosis with arthritis and believe they can wait for symptoms such as swelling and joint pain to occur before seeing a doctor. However, the mechanisms that cause arthritis are entirely different from those in osteoporosis. Osteoporosis usually becomes quite advanced before symptoms appear.

All too often, osteoporosis becomes apparent in dramatic fashion: a fracture of a vertebra (backbone), hip, forearm, or any bony site if sufficient bone mass is lost. These fractures frequently occur after apparently minor trauma, such as bending over, lifting, jumping, or falling from the standing position.

Pain, disfigurement, and debilitation are common in the latter stages of the disease. Early spinal compression fractures may go undetected for a long time, but after a large percentage of calcium has been lost, the vertebrae in the spine start to collapse, gradually causing a stooped posture called kyphosis, or a "dowager’s hump." Although this is usually painless, patients may lose as much as 6 inches in height.

Click the icon to see an image of osteoporosis.

Fractures

Bone density loss from osteoporosis is a major cause of disability and death in the elderly, mostly due to subsequent fractures. The lifetime risk of spinal fracture in women is about one in three, and that for hip fracture is one in six. Women at highest risk for fractures are those with low bone density plus a history of fractures, particularly nonviolent fractures.

Click the icon to see an animation about osteoporosis.

Each year, there are an estimated 500,000 spinal fractures, 300,000 hip fractures, 200,000 broken wrists and 300,000 fractures of other bones. About 80% of these fractures occur after relatively minor falls or accidents.

Between 25 - 60% of women older than age 60 develop spinal compression fractures. Studies on men with osteoporosis report that they have a 6% risk for hip fracture and between 16 - 25% risk for any fractures related to osteoporosis.

Click the icon to see an image of a compression fracture.

Click the icon to see an image of a hip fracture.

Unfortunately, studies continue to report inadequate treatment after a fracture. In a major 2003 study, for example, only 8.4% of women who had sustained fractures were tested for osteoporosis. Worse, less than half of these women received any treatment for osteoporosis. Overall, in the study fewer than 4% of men and half of women who had sustained fractures were evaluated and treated according to recommended guidelines. The older a woman was, the less likely she was to have adequate treatment.

Risk Factors for Fracture and Falling. The risk for fracture itself in people with low bone density is compounded by certain features. Having multiple risk factors for osteoporosis itself poses a higher risk for fractures. However, not all older women with osteoporosis develop fractures. There is some evidence that the body partially compensates after menopause by increasing bone strength, which can help offset the risk for fracture.

Falling, of course, is the primary risk factor for fracture. So, additional risk factors for fracture are those that increase the risk for falling. They include:

Having chronic medical problems (emphysema, heart disease, stroke, arthritis, and depression), with the risk increasing with multiple health problems. Such problems may account for 30% of falls in older women.
Taking multiple medications (especially tranquilizers and antidepressants).
Poor physical function, importantly slow gait and reduced muscle strength. Inactivity that results in weak thigh muscles and poor balance particularly puts any older person at risk for fracture and particularly those with low bone density.
Poor concentration or mental impairment.
Impaired vision.
Hazardous environment (such as the presence of throw rugs in the house).

Between 25 - 36% of women who experience a hip fracture die within a year afterward, and about a quarter of the patients require nursing home treatment. The mortality rates after major fractures may be even higher in older men than in older women. Mortality rates after hip fractures declined from the 1960s through the early 1980s, but they have since leveled off. Whether or not medical advances can improve mortality rates in the future, prevention of osteoporosis is extremely important.

Risk Factors

Gender. An estimated 10 million adults in the United States have osteoporosis and another 34 million have low bone mass that places them at risk for developing osteoporosis. A 2004 report from the Surgeon General's office estimates that by 2020, half of all Americans over age 50 could be at risk for this condition. Eighty percent of people with osteoporosis are women. Men start with higher bone density and lose calcium at a slower rate than women, which is why their risk is far lower. Nevertheless, after age 50, bone loss increases and, according to recent studies, more rapidly than previously thought.

Ethnicity. Although adults from all ethnic groups are susceptible to developing osteoporosis, Caucasian and Asian women and men face a comparatively greater risk. About 20% of non-Hispanic white and Asian women older than age 50 have osteoporosis, and over 50% are at risk due to low bone mass. Osteoporosis affects 10% of Hispanic women (49% at risk) and 5% of non-Hispanic black women (35% at risk). Body type can also be a factor. Osteoporosis is more common in women who have a small, thin body frame and bone structure.

Events associated with estrogen deficiencies are the primary risk factors for osteoporosis in women.

Natural and Surgical Causes of Estrogen Deficiency.

Menopause. Within 5 years after menopause, the risk for fracture increases dramatically. Fractures occurring during this period are more likely to occur in the wrist or spine than the hip, but their occurrence is a strong predictor of later severe osteoporosis and hip fracture.
Surgical removal of ovaries.
Missing periods for 3 months or longer.
Never giving birth.
Pregnancy and nursing do not increase the risk for osteoporosis even though during those times calcium is diverted from the mother to the baby. A factor believed to be associated with reduced bone density is elevated at a constant level during nursing, but as the baby is weaned, levels of the factor decline and bone formation is restored.

Female Athlete Triad. In athletes, excessive exercise plays a major role in many cases of anorexia (and, to a lesser degree, bulimia), which in turn increases the risk for low estrogen levels and bone loss. The term "female athlete triad" in fact, is now a common and serious disorder facing young female athletes and dancers and describes the combined presence of the following problems:

Osteoporosis
Amenorrhea (absence or irregular menstruation)
Eating disorders

Some specific risk factors in men include:

Hormonal deficiencies, including both testosterone and estrogen, which occur in older men (although much more slowly than in women). Estrogen deficiencies may also play a major role in osteoporosis in older men. It is unknown yet what normal estrogen levels are in men.
Medical conditions that can reduce testosterone levels, such as prostate cancer treatments, testicular surgery, and mumps.
Hypogonadism, which is a severe deficiency in the primary hormone that signals the process leading to the release of testosterone and other important reproductive hormones.

Of concern, are studies suggesting that men who have osteoporosis and suffer hip fractures are far less likely to be tested and treated for low bone density than are women. In one study, only 27% of men were treated for osteoporosis compared to 71% of women.

Dietary Factors. Diet plays an important role in preventing and speeding up bone loss in men and women. Calcium and vitamin D deficiencies, of course, are important factors in the risk for osteoporosis. Other dietary factors may also be harmful or protective for certain people.

Calcium requires adequate vitamin D in order to be absorbed by the body. In the United States, many food sources of calcium such as milk are fortified with vitamin D.

Click the icon to see an image of the sources of calcium.

Lack of Exercise. Lack of exercise can put thinner people at risk for osteoporosis.

Being Underweight. Being underweight is a risk factor for osteoporosis in men as well as women. (Shortness, thinness, and narrow hips all increase the risk for fracture in people with low bone density.)

Lack of Sunlight. The photochemical effect of sunlight on the skin is a primary source for vitamin D. Bone formation peaks in the summer and bone breakdown increases in the winter. People who avoid sun exposure to prevent skin cancer may be at risk for vitamin D deficiency, particularly it they are elderly.

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

Smoking. Women who smoke, particularly after menopause, have a significantly greater chance of spine and hip fractures than those who don’t smoke. Men who smoke also have lower bone density.

Diabetes. Diabetes changes bone quality and density and increases the risk for osteoporosis, but the effects differ depending on type:

Type 1 diabetes is associated with a slightly reduced bone density, putting patients at risk for osteoporosis and possibly fracture.
Type 2 diabetes, on the other hand, is associated with an increased bone density. In such cases, the bone quality itself may be impaired, since people with type 2 diabetes are still at higher risk for fractures.

Older patients with any diabetes type are at high risk for falling, which compounds the risk for fracture.

The maximum density that bones achieved during the growing years is a major factor in whether a person goes on to develop osteoporosis. Persons, usually women, who never develop peak bone mass in early life are at high risk for osteoporosis later on. Children at risk for low peak bone mass include children who are:

Born prematurely
Have anorexia nervosa (more common in girls)
Young, highly competitive athletes
Take oral corticosteroid drugs (inhaled steroids, which are common in asthma treatments, appear to pose a very low risk or none at all)
Have certain medical conditions (cystic fibrosis, epilepsy, inflammatory bowel disease, and celiac disease)
Have delayed puberty

Although to a large extent genetics predict bone health, exercise and good nutrition during the first three decades of life (when peak bone mass is reached) are still excellent safeguards against osteoporosis (and countless other health problems).

Diagnosis

About 20 - 30% of Caucasian women in the U.S. can expect to be affected by osteoporosis, including having a spinal fracture, after age 60. Hispanic, Asian, and Native American women have an even higher risk. Nearly all of them are unaware of the condition and so fail to seek a diagnosis. Even worse, studies continue to report inadequate evaluation for osteoporosis even after a fracture.

Evidence suggests that screening for osteoporosis can help prevent fractures. Expert groups now recommend bone density screening for the following people:

All women over age 65.
Any postmenopausal women under 65 years with risk factors for osteoporosis (being thin, being a smoker, having a family history of osteoporosis, corticosteroids use, or any serious high-risk condition, such as hyperthyroidism or early menopause).
Any older men or women who suffer a fracture. (Unfortunately, studies suggest that only a minority of these patients are evaluated and treated for osteoporosis. Men are especially less likely to be tested.)

Whether perimenopausal women should be screened is unclear. (Perimenopause is the period that extends a few years before and after menopause, usually ages 50 - 59.) Some experts believe that women as young as 21 who have strong risk factors for osteoporosis (such as anorexia or absence of menstruation due to over-exercising) should consider being tested. It is also important that older women continue to get bone density tests. A 2006 study found that only 10% of women over age 75 receive bone density screenings, even though they are the age group most likely to have hip fractures.

Bone Densitometry. The standard technique for determining bone density is a form of bone densitometry called dual-energy x-ray absorptiometry (DEXA). DEXA is simple and painless and takes 2 - 4 minutes. The machine measures bone density by detecting the extent to which bones absorb photons that are generated by very low-level x-rays. (Photons are atomic particles with no charge.) Measurements of bone mineral density are generally given as the average concentrations of calcium in areas that are scanned.

A bone density scan measures the density of bone in a person. The lower the density of a bone the higher the risk of fractures. A bone scan, along with a patient's medical history, is a useful aid in evaluating the probability of a fracture and whether any preventative treatment is needed. A bone density scan has the advantage of being painless and exposing the patient to only a small amount of radiation.

Bone mineral density is usually measured at the hip rather than the spine or wrist, which appears to be the most predictive of hip fracture. (Hip fractures are the most dangerous fractures, particularly in women older than sixty.) The bone density in the spine may also be measured. (Spinal bone density in older people however may be misleading. Bone density in this group may increase because of compression on the spinal bones from arthritic changes in the spine. Therefore, bone density measurements may be normal or even high, but the patient may actually be at risk for fracture.)

Click the icon to see an image of a hip fracture.

Ultrasound. Ultrasound techniques measure bone density in the heels, fingers, and leg bones. In early studies, advanced ultrasound techniques, such as quantitative ultrasound (QUS), are promising for improving accuracy in predicting fractures when used with DEXA. Ultrasound itself is less expensive than DEXA and uses no radiation. Ultrasound bone tests are sometimes given at health fairs or other non-medical settings. It should be noted that these results typically vary widely from measurements of the hipbone and are not reliable when used alone.

Quantitative Computed Tomography. Quantitative computed tomography (QCT) scans, a form of CT scans, can provide highly detailed information about spinal density. Radiation doses from this technique are higher than the others. Whether QCT predicts fracture risk accurately is, however, unknown.

Osteoporosis is diagnosed when bone density has decreased to the point where fractures will happen with mild stress, the so-called fracture threshold. This is determined by measuring bone density and comparing the results with the norm. However, low scores on bone density are not very accurate in determining fracture risk without consideration of other risk factors for fracture.

In general, doctors take the following steps to determine osteoporosis:

Bone mineral density ) is measured, typically in the hipbone, using bone densitometry.
Measurements of bone mineral density are given as mg/cm.² This is the average concentration of bone mineral in the areas that are being scanned. In general, bone is normal if results are greater than 833 mg/cm.² Low bone density (osteopenia) is between 833 and 648 mg/cm.² Osteoporosis is diagnosed with results below 648 mg/cm.²

These measurements still do not always indicate the true risk for fracture. The doctor also assesses risk factors and other considerations. The next step is to compare the patient's bone mineral density to normal bone density, which is defined as the average bone mineral density in the hipbones of premenopausal Caucasian women. (This group is used as the basis for the norm because of their high risk and greater proportion in the American population.)

The health professional then uses this comparison to determine her standard deviation (SD) from this norm. Standard deviation results are given as Z and T scores:

A T score gives the standard deviation of the patient in relationship to the norm in young adults. Doctors often use the T-score and other risk factors to determine the risk for fracture.
A Z score gives the standard deviation of the patient in relationship to the norm in her own age group. Z scores may be used to monitor the effects of treatments in women who have been diagnosed with osteoporosis.

For example, the lifetime risks for a younger woman with a specific T-score would be higher than the same scores in an older woman because the younger woman would have a longer time to lose bone density. In general, the T scores in a 55-year-old woman suggest the following degrees of risk for hip fracture.

One standard deviation or less below the norm indicates normal bone mineral density. (This carries a lifetime chance for a hip fracture of up to about 20%, depending on age and other risk factors.)
Between 1 and 2.5 standard deviation s below normal defines osteopenia, which is low bone density. This carries between a 20 - 50% lifetime risk for fracture.
More than 2.5 standard deviation s predicts osteoporosis and over a 60% chance for hip fracture. Additional risk factors increase the risk. They include low weight, smoking, risks for falling, and especially a history of previous fractures. For example, in women 65 years old with low bone density but no adverse factors, the risk for fracture is 4.3% in 1 year and 28.6% over 5 years. In similar women with a previous fracture, the probability of fracture at 1 year is 11% and at 5 years is 71.8%.

Not all older women with osteoporosis develop fractures. There is some evidence that the body partially compensates after menopause by increasing bone strength, which can help offset the risk for fracture. Techniques to measure bone strength may better identify women at higher or lower risk.

Note: Because the standards are based on Caucasian women, they do not necessarily apply to men, children, or to non-Caucasian women. For example, men have a lower risk for fracture at the same standard deviations as women. Researchers are attempting to establish risk guidelines for these groups as well.

Laboratory blood or urine tests for identifying certain markers of bone loss may prove to be useful in certain cases:

High levels of the chemicals deoxypyridinoline and C-telopeptide in the blood may indicate increased risk for hip fracture. These substances are produced when bone is broken down.
A urine test detecting a substance called N-telopeptide may indicate bone loss (although it is not associated with any risk for fracture).

Lifestyle Changes

Because osteoporosis affects such a considerable portion of the female population, total prevention may not be possible, particularly for high-risk groups. Once a woman goes through menopause and more rapid bone depletion occurs, the line between prevention and treatment blurs. Despite their lower risk for osteoporosis, men should also protect their bones with the same healthy lifestyle habits.

Exercise is very important for slowing the progression of osteoporosis. Although mild exercise does not protect bones, moderate exercise (more than 3 days a week for more than a total of 90 minutes a week) reduces the risk for osteoporosis and fracture in both older men and women. Everyone who is in good health should aim for more. Exercise should be regular and life-long. Before beginning any strenuous exercise program, older patients, those at risk or those who have serious medical conditions, should talk to their doctors.

Specific exercises may be better than others, depending on the age group:

Children should begin exercising before adolescence, since bone mass increases during puberty and reaches its peak between ages 20 and 30. Some evidence suggests that exercise may help develop bone mass in teenagers more effectively than high calcium intake. High-intensity exercises may be particularly bone-strengthening in young people. (Such regimes should not be confused with the athlete-triad -- intense competitive exercise, eating disorders, and menstrual irregularities -- that causes osteoporosis in young athletes.)
Weight-bearing exercise applies tension to muscle and bone and, in young people, encourages the body to compensate for the added stress, increasing bone density by as much as 2 - 8% a year. In premenopausal women these exercises are very protective. (Young men need high-intensity exercises to increase bone mass.) Careful weight training is also very beneficial for elderly people, especially women.
Regular brisk long walks improve bone density and mobility and may relieve osteoarthritic pain. High-impact exercises can be very bone-protective in young and middle-aged adults who have no precluding medical or physical conditions. Most older individuals should avoid high-impact aerobic exercises (step aerobics), which increase the risk for osteoporotic fractures. (Older people, particularly women who engage in jumping exercises should do so under supervision.) Although low-impact aerobic exercises such as swimming and bicycling do not increase bone density, they are excellent for cardiovascular fitness and should be part of a regular regimen.
Exercises specifically targeted to strengthen the back help prevent fractures later on in life and can be beneficial in improving posture and reducing kyphosis (hunchback), even in people with existing severe conditions.
Low-impact exercises that improve concentration, balance, and strength, particularly yoga and tai chi, have been found to decrease the risk of falling. In one study, tai chi reduced the risk of falling by almost half.

Exercise plays an important role in the retention of bone density in the aging person. Studies show that exercises requiring muscles to pull on bones cause the bones to retain and possibly gain density.

Click the icon to see an image of osteoporosis.

In 2007, the Food and Drug Administration (FDA) proposed a new health claim for foods and dietary supplements that contain calcium and vitamin D. The FDA’s recommendation will allow manufacturers of these products to state that the combination of calcium and vitamin D can reduce the risk of osteoporosis. Also in 2007, the National Osteoporosis Foundation (NOF) updated its recommendations for getting enough calcium and vitamin D3. The NOF now recommends 1,200 mg of calcium/day and 800 - 1,200 I.U. of vitamin D3/day for adults age 50 and older. (For strong bones, people need enough of both calcium and vitamin D.)

For years, doctors have recommended that women take supplements of calcium plus vitamin D to help maintain bone density and reduce the risk for fractures. Many studies, including a 2007 review in the Lancet, show that a combination of calcium and vitamin D can help prevent osteoporosis. However, a 2006 New England Journal of Medicine study raised some questions about this approach. In the Women’s Health Initiative study, women were randomly assigned to receive either 1,000 mg of calcium carbonate plus 400 IU of vitamin D a day or placebo. The results indicated that daily calcium and vitamin D supplements:

Improve slightly (by 1%) hip bone density
Prevent hip fracture, but only for women who consistently take the supplements. (Another 2006 study supported this finding.)
Do not prevent spine or other types of fractures
Produce a slight increase in the risk of kidney stones

The medical community has differing views on how to interpret these findings. Some doctors recommend that women over age 60 should still consider taking calcium and vitamin D for bone health. Other doctors feel that due to the risks of kidney stones, supplements are beneficial only for women (especially those over age 70) who do not get enough calcium in their diets. Ask your doctor whether or not you should take calcium supplements.

Appropriate Daily Doses. Recommended daily amounts of calcium depend on age and risk factors:

In young people, children ages 3 - 8 should take 800 mg of calcium per day, while children and adolescents ages 9 - 17 need 1,300 mg per day. Teenage girls who do not have enough calcium in their diets should consider taking supplements, which can help build bone density during these critical years.
The standard recommended dose for people over age 50 is about 1,200 mg per day, but actual dosage may be higher or lower depending on risk factors. Even doses of 1,000 mg may help preserve bone in many postmenopausal women without osteoporosis, including during winter months (when bone loss is greatest). In women who have already experienced osteoporosis-related fractures, however, 1,000 mg daily may not add any protective benefits without bone-building medication.
Some experts suggest that all pregnant women, adolescents, and those on corticosteroids take 1,000 - 1,300 mg of calcium every day.
Breast-feeding women should have 2,000 mg per day.

Forms of Calcium Supplements. There are several different kinds of calcium supplements, such as calcium carbonate (Caltrate, Os-Cal, Tums), calcium citrate (Citracal), calcium gluconate, and calcium lactate. Although each kind provides calcium, they all have different calcium concentrations, absorption capabilities, and other actions. Their value in preserving bones depends on many different factors:

Calcium Concentrations. Forty percent of calcium carbonate is actually calcium, whereas calcium citrate is 24% calcium, and calcium gluconate is only 9% calcium.
Calcium Absorption Capabilities. The calcium must also be absorbed from the stomach into the bloodstream. Calcium citrate is better absorbed than many other calcium compounds. It was reported to be the first calcium supplement to preserve bone density after menopause. (Calcium citrate also increases iron absorption. Milk and other calcium compounds tend to reduce iron absorption.) One simple method for testing the absorbency of a particular brand of calcium tablet is to place it in a glass of white vinegar at full strength and check to be sure that it breaks up within 30 minutes. Taking large amounts of antacids can impair calcium absorption. People should take calcium supplements after meals.

Side Effects. Calcium supplements, even at normal doses of about 1,000 mg a day, can increase the risk for kidney stones. People should be careful not to exceed the upper limit of 2,500 mg per day. (Because many commercial foods are now fortified with calcium, this upper limit may be easier to reach than people think.) Calcium may boost the effects of drugs used to treat osteoporosis.

Click the icon to see an image of kidney stones.

Although not a specific side effect of calcium, there has been much public concern about reports of a small amount of lead in calcium supplements. Although exposure to high levels of lead can cause health problems, the amount in such supplements is very small and may pose little or no hazard.

Vitamin D. Vitamin D helps the stomach and the gastrointestinal tract absorb calcium. It also is the essential companion to calcium in maintaining strong bones. Moreover, vitamin D protects against osteoporosis only in combination with calcium.

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

Vitamin D is made in the skin using energy from the ultraviolet rays in sunlight. People also can get it from dietary supplements.

As a person ages, vitamin D levels decline. They also fall during winter months and when people have inadequate sunlight. Pollution may also contribute to less sunlight and declining vitamin D levels.

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

Most current adult guidelines recommend:

400 IU (10 mcg) for people aged 50 - 60.
600 IU (15 mcg) for those over age 70 who do not have sufficient exposure to sunlight. (Evidence suggests that higher doses of vitamin D -- up to 1,000 IU per day -- may help prevent fractures in people with osteoporosis.)

There are various recommendations for daily vitamin D intake. In 2007, the National Osteoporosis Foundation updated its guidelines to recommend 400 - 800 IU of vitamin D3 for adults younger than age 50, and 800 - 1,000 IU of vitamin D3 for adults age 50 and older. Vitamin D3, also called cholecalciferol, is the form of vitamin D that is best for bone health. In addition to supplements, food sources for vitamin D3 include fortified milk, egg yolks, saltwater fish, and liver.

In 2007, the U.S. National Institute of Health’s Office of Dietary Supplements released a report regarding vitamin D and bone health. Researchers were not able to definitely separate the effect of vitamin D from that of calcium, as most clinical trials evaluate the combination of these supplements. The report did indicate that a combination of daily vitamin D3 (700 - 800 IU) and calcium (500 - 1,200 mg) decreases the risks of falls, fractures, and bone loss in elderly people (ages 62 - 85 years).

Sufficient sunlight exposure and drinking milk fortified with vitamin D supply most people’s normal needs for vitamin D. One cup of whole milk provides about 100 IU of vitamin D.

Vitamin D is toxic in doses above 2,000 IU a day. No one should exceed the recommended daily intake of vitamin D except under the direction of a doctor.

Many people could become deficient in vitamin D as they avoid sunlight to prevent skin cancers and instead increase their intake of milk products, such as yogurt and skim milk, which may have little vitamin D. Such individuals may need to take supplements. People with darker skin have a higher risk for vitamin D deficiency than those with lighter skin.

Vitamin D derivatives are being investigated for treating osteoporosis. Calcitriol (Calcijex, Rocaltrol), for example, is a prescription-form of vitamin D that can increase bone mass and decrease the rate of spinal fractures. However, calcitriol increases the risk for high blood calcium levels (hypercalcemia) and requires frequent monitoring.

Vitamin K. Vitamin K has properties that protect bone and prevent fracture. Because intestinal bacteria produce vitamin K, and the vitamin is found in leafy vegetables, deficiencies are rare. Some evidence suggests, however, that people may not be consuming enough of this nutrient. Vitamin K affects blood clotting, and taking supplements is not recommended without first talking to a doctor. Vitamin K2 (menatetrenone), a form of vitamin K, may help prevent fractures in people with osteoporosis.

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

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

Vitamin B12. Studies suggest that people need the right amounts of vitamin B12 and folic acid to maintain their bone mineral density.

Vitamin A. High amounts of dietary vitamin A reduce bone density and may even increase the risk for fracture in postmenopausal women. (A form of vitamin A, retinoic acid, has been found to stimulate bone breakdown.)

The DASH Diet and Low Sodium. Perhaps a good general approach for people at risk for osteoporosis (or almost any adult) is the DASH diet plus sodium (salt) restriction. The DASH (Dietary Approaches to Stop Hypertension) diet is used to help people with hypertension maintain healthy blood pressures. A 2003 study also reported that it might help protect bones and improve cholesterol levels. This diet not only is rich in important nutrients and fiber but also includes foods that contain far more potassium, calcium, and magnesium, than are found in the average American diet. All of these minerals are important for bone protection. The dietary recommendations are as follows:

Avoid saturated fat (although include calcium-rich dairy products that are no- or low-fat). When choosing fats, select monounsaturated oils, such as olive or canola oils. These fats are also found in some fish. Although no one wants to be overweight, even a slight excess of fat helps protect bones. In one study, women who ate more fat in their diet were, on average, better able to absorb calcium than were women who had been put on a low-fat, high-fiber diet.
Choose whole grains over white flour or pasta products. Include nuts, seeds, or legumes (dried beans or peas) daily.
Choose fresh fruits and vegetables every day. Many of these foods are rich in potassium, magnesium, and other minerals that are important for bone (as well as heart) protection.
Choose protein preferably from fish, poultry, or soy products. Soy in combination with fiber-rich foods or supplements may have specific benefits. Oily fish may also be particularly beneficial. They contain omega-3 fatty acids, which have been associated with heart and nerve protection.

Salt Restriction. Reducing salt may protect both the heart and the bones. High sodium intake interferes with calcium retention. Note: Fast foods and commercial snacks are usually high in sodium and have been linked with weak bones.

Dairy Products and Calcium-Rich Foods. Although some studies have reported that dairy products benefit the bones, it is not entirely clear if high-calcium diets reduce the risk for fractures compared to adequate intake of vitamin D. Until more is known, people should be sure their diets have sufficient calcium. Dietary calcium is available from many good sources.

Milk and Dairy Products. The best source of calcium in the diet is from milk fortified with vitamin D. Four glasses of milk provide about 1,200 mg of calcium. (Skim milk and yogurt products, unfortunately, are often low in vitamin D, which is important for calcium absorption.) According to a 2003 study, girls who have low milk intake increase their risk for fracture in adulthood. One report even suggests that milk proteins actually slow bone break down. It is not clear, however, if drinking milk after menopause offers any significant bone protection.
Other Calcium-Rich Foods. Other calcium-rich foods include shrimp, canned salmon or sardines, black strap molasses, calcium-fortified tofu, and almonds. A number of commercial foods, including orange juice and some cereals, are now calcium fortified. Dark green vegetables (broccoli, kale, turnip greens) are rich in calcium but little of it is absorbed (kale is best).

Click the icon to see an image of milk and the facial bones.

Mineral-Rich Fruits and Vegetables.

Potassium. Potassium may be very important for strong bones and may help counteract negative effects of high-protein diets. Potassium-rich fruits include bananas, oranges, prunes, and cantaloupes, and vegetables that contain potassium include carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados, and broccoli.
Magnesium. Some studies have observed that low levels of magnesium may contribute to thinning bones. Some studies suggest that magnesium supplements help suppress the cycle that leads to bone loss. Experts recommend 350 mg a day for supplements. However, excessive magnesium may be harmful in people with diabetes or kidney disease. Foods rich in magnesium include dairy products, spinach, potatoes, beets, nuts, sole, and halibut.
Other Minerals. Phosphorous, boron, and zinc have also been associated with bone protection.

Protein. Protein may be important for frail older people for improving muscle strength. Researchers, meanwhile, have associated both low and high protein intake with bone loss. Protein deficiencies appear to trigger hormonal changes that increase bone breakdown. On the other hand, high protein intake increases urinary calcium loss, which can impair bone density in people with low-calcium diets. High-protein diets, however, do not appear to cause bone loss if calcium intake is also high. The bottom line is to eat enough protein but to balance it with plenty of calcium-rich, and other mineral-rich, foods.

The protein source (meat, soy, or fish) may have some effect on bone density, although the effects are not clear. Studies are mixed on whether protein from meat has a positive or negative effect on bone loss. In any case, the best sources of protein for bone protection may be from oily fish or soy.

Choosing protein from fish (especially oily fish such as sardines, salmon, mackerel, fresh tuna, and herring) is a good option. Oily fish are high in vitamin D, which is bone protective. Such fish are also heart protective. Wild salmon has a much higher vitamin D content than farmed salmon. American brands of canned tuna, meanwhile, generally do not contain significant amounts of vitamin D.
Soy may have some modest protection against bone loss. Soy is high in estrogen-like plant chemicals called isoflavones, which may improve bone health in older women. In particular, the isoflavone genistein is being studied for its effects on bone health. A small 2007 study indicated that genistein supplements, when taken with vitamin D and calcium, may help improve bone density in postmenopausal women with thinning bones. (However, other studies indicate that soy has no effect on bone density in healthy premenopausal women.) Soy food products that also contain calcium, such as tofu, may be particularly beneficial. In such cases, 3 ounces of tofu supply 60% of daily calcium requirements.

Alcohol. Alcohol has different effects on bones depending on how much is consumed. One study found that women older than age 65 who drank one to two drinks (1 - 2 oz) of alcohol weekly had higher bone density than non-drinkers. Alcohol in moderate amounts may reduce parathyroid hormone and increase estrogen levels. Excessive drinking, however, has been associated with brittle bones.

Cola, Coffee, Tea and Caffeine. One study suggested that drinking tea regularly may help protect bones. Nevertheless, there has been some concern that caffeine consumption, particularly from coffee, may increase calcium levels in urine and reduce levels in the body. In one trial, consumption of lots of coffee (9 or more cups per day) was associated with an increased risk of hip fractures in women, but not in men. However, not all studies support a risk. Some evidence suggests that caffeine may pose a danger for bone loss only in elderly thin women -- but not in those who have normal or high weight. Drinking carbonated beverages, particularly cola, may increase the risk for bone fractures in people with low bone density.

Everyone who smokes should quit. The risk for osteoporosis from smoking appears to diminish after quitting.

An important component in reducing the risk for fractures is preventing falls. Risk factors for falling include:

Slow walking
Inability to walk in a straight line
Certain medications (such as tranquilizers and sleeping pills)
Low blood pressure when rising in the morning
Poor vision

Recommendations for preventing falls or fractures from falls in elderly people include:

Exercise to maintain strength and balance if there are no conflicting medical conditions. In one study of older people, this was the single best intervention for preventing falls.
Do not use loose rugs on the floors.
Move any obstructions to walking, such as loose cords or very low pieces of furniture, away from traveled areas.
Rooms should be well lit.
Have regular eye checkups.
Try wearing hip pads. Hip pads are specially designed to protect hipbones against falls and are worn under clothing. Evidence on their protection against fractures is weak, however, particularly since compliance is poor. Nevertheless, newer hip pads that are thinner and made with newer materials may be helpful and more appealing.
Wear thinner, hard-soled shoes. Studies indicate these shoes are just as comfortable as the popular resilient-soled footwear, but they may be difficult to find. Soft-soled high-resilient so-called athletic footwear may contribute to impaired balance and dangerous falls, in part, because these cushioned shoes offer less stability.

Medications

Many drugs are available to treat osteoporosis. Unfortunately, studies continue to report that doctors fail to evaluate and adequately treat both men and women for this condition, even after a fracture. According to one study of women over age 60, fewer than 2% were evaluated for osteoporosis or spinal fracture by their doctors. Among those who were diagnosed, only 36% received appropriate medication. Among adults who had sustained fractures, less than 5% of men and fewer than half of women were evaluated and treated according to recommended guidelines, indicated two other studies. In one of the studies, only 24% of women received treatment for osteoporosis after a fracture. In both studies, the older a woman was, the less likely she was to have adequate evaluation or treatment.

Drugs Used to Treat Osteoporosis. Two types of drugs are used to treat osteoporosis:

Antiresorptive Drugs. Antiresorptives include bisphosphonates, hormone replacement therapy, selective estrogen-receptor modulators (SERMs), and calcitonin. Bisphosphonates are the standard drugs used for osteoporosis. These drugs block resorption (preventing bone break down), which slows the rate of bone remodeling, but they cannot rebuild bone. Because resorption and reformation occur naturally as a continuous process, blocking resorption may eventually also reduce bone formation.
Anabolic, or Bone-Forming, Drugs. Drugs that rebuild bone are known as anabolics. The primary anabolic drug is low-dose parathyroid hormone (PTH), which is administered through injections. This medicine is proving to be very effective in restoring bone and preventing fractions. PTH is still relatively new, and long-term effects are still unknown. Fluoride is another bone-building drug, but it has limitations and is not commonly used.

Both types of drugs are effective in preventing bone loss and fractures, although they vary in their effectiveness and safety.

Bisphosphonates are antiresorptive drugs. They are the primary drugs for preventing and treating osteoporosis. They can help reduce the risk of both spinal and hip fractures, including among patients with prior bone breaks.

Studies indicate that these drugs are effective and safe for at least 10 years. Eventually, however, bone loss continues with bisphosphonates. This may be due to the fact that bone breakdown is one of two phases in a continuous process of rebuilding bone. Over time, just blocking resorption will interrupt this process and impair the second half of the process -- bone formation. Some researchers think that this problem may be overcome by building bone for a couple of years with parathyroid hormone (PTH), then following this treatment with bisphosphonates to prevent the breakdown of bone. (Administering the two drugs simultaneously is not effective because bisphosphonates interfere with the way PTH works.)

A 2006 study of the bisphosphonate alendronate (Fosamax), the most widely used osteoporosis drug, indicated that women at low risk for fracture may be able to stop using the drug after 5 years without increasing their fracture risk for another 5 years. However, the Journal of the American Medical Association study also suggested that it is safer for women at high risk for spine fractures to keep taking alendronate on a continuous basis.

Candidates. National Osteoporosis Foundation guidelines recommend that the following people should take or consider bisphosphonates:

Women with a below-normal bone density of 2.5 standard deviation or greater and no history of fractures
Women with below-normal bone density 1 standard deviation or more and a history of fractures

Brands. Bisphosphonates are available in different forms:

Oral bisphosphonates. These pills include alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). Alendronate and risedronate are taken once a week. In 2005, ibandronate was approved as the first once-monthly pill. Risedronate is also available in a pill that contains calcium. Risedronate and alendronate are approved for both men and women.
Injectable bisphosphonates. In 2007, zoledronic acid (Reclast) was approved as the first once-yearly injection treatment for osteoporosis. The injectable form of ibandronate (Boniva), approved in 2006, requires injections 4 times a year. Injectable bisphosphonates are an alternative for patients who may have difficulty swallowing pills or sitting upright after oral bisphosphonate treatment.

Side Effects. The most distressing side effects of bisphosphonates are gastrointestinal problems, particularly stomach cramps and heartburn. These symptoms are very common and occur in nearly half of all patients. Other side effects may include irritation of the esophagus (the tube that connects the mouth to the stomach) and ulcers in the esophagus or stomach. Some patients may experience muscle and joint pain. To avoid stomach problems, doctors recommend:

Take the pill on an empty stomach in the morning with 6 - 8 ounces of water (not juice or carbonated or mineral water).
After taking the pill, remain in an upright position. Do not eat or drink for at least 30 - 60 minutes. (Check your drug’s dosing instructions for exact time.)
If you develop chest pain, heartburn, or difficulty swallowing, stop taking the drug and see your doctor.

Osteonecrosis (bone death) of the jaw is a rare side effect that has occurred mainly in patients who received intravenous bisphosphonates for cancer treatment (not osteoporosis). Many of these patients had major dental procedures before developing osteonecrosis. However, this bone decay condition has also been reported in some patients who have taken bisphosphonates by mouth (mainly alendronate). Symptoms may include jaw pain or swelling, gum infections, and poor healing of the gums. Talk to your doctor or dentist if you experience any jaw or gum discomfort while taking a bisphosphonate drug.

Raloxifene (Evista) belongs to a class of drugs called selective estrogen-receptor modulators (SERMs). These drugs are similar, but not identical, to estrogen. Raloxifene provides the bone benefits of estrogen without increasing the risks for estrogen-related breast and uterine cancers. Raloxifene was approved in 1997 to prevent osteoporosis in postmenopausal women, and in 1999 for the treatment of osteoporosis in postmenopausal women. In 2007, the Food and Drug Administration approved raloxifene for prevention of breast cancer in postmenopausal women with osteoporosis, as well as postmenopausal women at high risk for invasive breast cancer.

While there are many SERM drugs, raloxifene is the only one approved for both treatment and prevention of osteoporosis. Only postmenopausal women who have or are at risk for osteoporosis should take this drug. Studies indicate that raloxifene can stop the thinning of bone and help build better quality and stronger bone.

A thrombus is a blood clot that forms in a vessel and remains there. An embolism is a clot that travels from the site where it formed to another location in the body. Thrombi or emboli can lodge in a blood vessel and block the flow of blood in that location, depriving tissues of normal blood flow and oxygen. This can result in damage, destruction (infarction), or even death of the tissues (necrosis) in that area.

Side Effects. Raloxifene increases the risk for blood clots in the veins. Because of this side effect, raloxifene also increases the risk for stroke (but not other types of heart disease). These side effects, though rare, are very serious. Women should not take this drug if they have a history of blood clots, or if they have certain risk factors for stroke and heart disease. More common mild side effects include hot flashes and leg cramps.

Produced by the thyroid gland, natural calcitonin regulates calcium levels by inhibiting the osteoclastic activity, the breakdown of bone. The drug version is derived from salmon and is available as a nasal spray (Miacalcin) and an injected form (Calcimar). Calcitonin is not used to prevent osteoporosis. It treats osteoporosis. It may be effective for spinal protection (but not hip) in both men and women. Calcitonin may be an alternative for patients who cannot take a bisphosphonate or SERM. It also appears to help relieve bone pain associated with established osteoporosis and fracture.

Side Effects. Side effects include headache, dizziness, anorexia, diarrhea, skin rashes, and edema (swelling). The most common adverse effect experienced with the injection is nausea, with or without vomiting. This occurs less often with the nasal spray. The nasal spray may cause nosebleeds, sinusitis, and inflammation of the membranes in the nose. Also, many people who take calcitonin develop resistance or allergic reactions after long-term use.

Although high persistent levels of parathyroid hormone (PTH) can cause osteoporosis, daily injections of low and intermittent doses of this hormone actually stimulate bone production and increase bone mineral density. In clinical studies, teriparatide (Forteo), a drug made from selected amino acids found in parathyroid hormone, reduced the risk for spinal and non-spinal fractures by 50 - 65%. It may prove to be a very useful drug for men with osteoporosis. Unlike most treatments for osteoporosis, including bisphosphonates, the benefits may persist even after the injections have been stopped.

Although the treatment requires injections, researchers are investigating a nasal spray version of PTH. In addition to easing patient discomfort, there is some preliminary evidence that nasal-administered PTH may be better absorbed than injections. Side effects of PTH are generally mild and include nausea, dizziness, and leg cramps. No significant complications have been reported to date.

Early animal studies did report bone tumors in mice that were given parathyroid long-term. Such effects have not been observed in humans to date. However, people with Paget disease, (a disorder in which bone thickens but also, oddly, weakens), should not take parathyroid hormone, since they are at higher than normal risk for bone tumors.

Hormone replacement therapy (HRT) is sometimes used to prevent osteoporosis. A Women’s Health Initiative (WHI) study found that women who received estrogen, or estrogen plus progestin, therapy had fewer fractures than women who received placebo.

However, WHI studies have also shown that estrogen increases the risk for breast cancer, blood clots, strokes, and heart attacks. For this reason, women need to balance the benefits that HRT has on bone-loss protection, with the risks it carries for other serious health conditions. The Food and Drug Administration recommends that women first try other medications for prevention of osteoporosis.

HRT is available in many different forms, including pills and skin patches. [See In-Depth Report #40: Menopause.]

New SERMs. Bazedoxifene (Viviant) is a new selective estrogen receptor modulator (SERM) that is in phase III clinical trials. In research presented at the 2007 annual meeting of the American Society for Bone and Mineral Research (ASBMR), bazedoxifene reduced new cases of non-spine fracture by 52% compared to placebo.
Biologic Drugs. Denosumab is a humanized monoclonal antibody injectable drug currently in phase III studies. It targets the RANK ligand, a protein involved with cells that break down bone (osteoclasts). Results presented at the 2007 ASBMR meeting indicated that denosumab may help increase bone mineral density by as much as 10.6%. Odanacatib is another biologic drug showing promise in phase IIB trials. Odanacatib inhibits cathepsin K, a protein that also plays a role in osteoclast activity.
Strontium. Strontium, a chemical element found in bone, may help increase bone formation and decrease bone resorption. NB S101 is a strontium drug currently in phase II trials.

Treatment

Nonsurgical treatments for fractures include braces, plaster cases, and manipulation of the fracture. Such approaches have not been well studied to determine an optimal method, and patients should discuss all options with their doctors.

Reconstructive surgery is usually used for hip fractures and should be performed within 48 hours, assuming the patient has no other complicating medical conditions. After surgery, the patient should be mobilized within the first day. In one study, protein supplements helped people with hip fractures recover more quickly and reduced bone loss.

Percutaneous vertebroplasty and kyphoplasty are surgical procedures used to lessen pain. Research to date suggests that they are safe and provide pain relief for many patients. In some cases they may increase height. There have been few controlled trials, however, and more research is needed to determine long-term effects.

Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into damaged vertebrae. It is proving useful for stabilizing the spine and relieving pain in patients with spinal compression fractures due to osteoporosis or cancer. Success rates of over 90% have been reported. Serious complications occur in fewer than 1% of cases.

Kyphoplasty. Kyphoplasty is a variant of percutaneous vertebroplasty that may help prevent kyphosis (hunchback) in patients whose spines have collapsed. The procedure inserts a balloon into the fractured vertebrae. As the balloon inflates, the spine is moved upward, to its original location. The balloon is then removed, and the bone and the core of the newly-erect vertebrae are filled with cement. In one 2003 study, short-term symptom relief improved by 70% and was immediate. Long-term effectiveness is not yet known.

Resources

www.nof.org -- National Osteoporosis Foundation
www.niams.nih.gov/Health_Info/Bone -- National Institutes of Health, Osteoporosis and Related Bone Diseases
www.menopause.org -- North American Menopause Society
www.asbmr.org -- American Society for Bone and Mineral Research
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases

References

Agency for Healthcare Research and Quality. Effectiveness and Safety of Vitamin D in Relation to Bone Health, Structured Abstract. August 2007. Rockville, MD.

Bilezikian JP. Osteonecrosis of the jaw -- do bisphosphonates pose a risk? N Engl J Med. 2006 Nov 30;355(22):2278-81.

Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007 May 3;356(18):1809-22.

Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, et al. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006 Dec 27;296(24):2927-38.

Diem SJ, Blackwell TL, Stone KL, Yaffe K, Haney EM, Bliziotes MM, et al. Use of antidepressants and rates of hip bone loss in older women: the study of osteoporotic fractures. Arch Intern Med. 2007 Jun 25;167(12):1240-5.

Haney EM, Chan BK, Diem SJ, Ensrud KE, Cauley JA, Barrett-Connor E, et al. Association of low bone mineral density with selective serotonin reuptake inhibitor use by older men. Arch Intern Med. 2007 Jun 25;167(12):1246-51.

Marini H, Minutoli L, Polito F, Bitto A, Altavilla D, Atteritano M, et al. Effects of the phytoestrogen genistein on bone metabolism in osteopenic postmenopausal women: a randomized trial. Ann Intern Med. 2007 Jun 19;146(12):839-47.

Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007 Aug 25;370(9588):657-66.

Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006 Dec 27;296(24):2947-53.

Review Date:
11/1/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Scoliosis

admin — Wed, 03 Sep 2008 17:55:21 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Scoliosis is a curving of the spine. The spine curves away from the middle or sideways.

Alternative Names

Spinal curvature; Kyphoscoliosis

Causes, incidence, and risk factors

There are three general causes of scoliosis:

Congenital (present at birth) scoliosis is due to a problem with the formation of the spine bones (vertebrae) or fused ribs during development in the womb.
Neuromuscular scoliosis is caused by problems such as poor muscle control or muscle weakness, or paralysis due to diseases such as cerebral palsy, muscular dystrophy, spina bifida, and polio.
Idiopathic scoliosis is scoliosis of unknown cause. It appears in a previously straight spine.

Idiopathic scoliosis in adolescents is the most common type. Some people may be prone to curving of the spine. Most cases occur in girls. Curves generally worsen during growth spurts. Scoliosis in infants and young children are less common, and commonly affect boys and girls equally.

Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. Untrained observers usually can't notice the curving.

Routine scoliosis screening is now done in middle and junior high schools. Many cases, which previously would have gone undetected until they were more advanced, are now being caught at an early stage.

There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation results. The greater the initial curve of the spine, the greater the chance the scoliosis will get worse after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) can cause breathing problems.

Symptoms

Backache or low-back pain
Fatigue
Shoulders or hips appear uneven
Spine curves abnormally to the side (laterally)

Note: Kyphoscoliosis also involves abnormal front-to-back curvature, with a "rounded back" appearance. See kyphosis.

Signs and tests

The health care provider will perform a physical exam, which includes a forward bending test that will help the doctor define the curve. The degree of curve seen on an exam may underestimate the actual curve seen on an x-ray, so any child found with a curve is likely to be referred for an x-ray. The health care provider will perform a neurologic exam to look for any changes in strength, sensation, or reflexes.

Tests may include:

Scoliometer measurements (a device for measuring the curvature of the spine)
Spine x-rays (taken from the front and the side)
MRI (if there are any neurologic changes noted on the exam or if there is something unusual in the x-ray )

Treatment

Treatment depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do. Most cases of adolescent idiopathic scoliosis (less than 20 degrees) require no treatment, but should be checked often, about every 6 months.

As curves get worse (above 25 to 30 degrees in a child who is still growing), bracing is usually recommended to help slow the progression of the curve. There are many different kinds of braces used. The Boston Brace, Wilmington Brace, Milwaukee Brace, and Charleston Brace are named for the centers where they were developed.

Each brace looks different. There are different ways of using each type properly. The selection of a brace and the manner in which it is used depends on many factors, including the specific characteristics of the curve. The exact brace will be decided on by the patient and health care provider.

A back brace does not reverse the curve. Instead, it uses pressure to help straighten the spine. The brace can be adjusted with growth. Bracing does not work in congenital or neuromuscular scoliosis, and is less effective in infantile and juvenile idiopathic scoliosis.

Curves of 40 degrees or greater usually require surgery because curves this large have a high risk of getting worse even after bone growth stops. Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is done through a cut in the back, on the abdomen, or beneath the ribs. A brace may be required to stabilize the spine after surgery.

The limitations imposed by the treatments are often emotionally difficult and may threaten self-image, especially of teenagers. Emotional support is important for adjustment to the limitations of treatment.

Physical therapists and orthotists (orthopedic appliance specialists) can help explain the treatments and make sure the brace fits comfortably.

Support Groups

See scoliosis - support group

Expectations (prognosis)

The outcome depends on the cause, location, and severity of the curve. The greater the curve, the greater the chance the curve will get worse after growth has stopped.

Mild cases treated with bracing alone do very well. People with these kinds of conditions tend not to have long-term problems, except maybe an increased rate of low back pain when they get older. People with surgically corrected idiopathic scoliosis also do very well and can lead active, healthy lives.

Patients with neuromuscular scoliosis have another serious disorder (like cerebral palsy or muscular dystrophy) so their goals are much different. Often the goal of surgery is simply to allow a child to be able to sit upright in a wheelchair.

Babies with congenital scoliosis have a wide variety of underlying birth defects. Management of this disease is difficult and often requires many surgeries.

Complications

Emotional problems or lowered self-esteem may occur as a result of the condition or its treatment (specifically, wearing a brace)
Failure of the bone to join together (very rare in idiopathic scoliosis)
Low back arthritis and pain as an adult
Low back arthritis and pain as an adult
Respiratory problems from severe curve
Spinal cord or nerve damage from surgery or severe, uncorrected curve
Spine infection after surgery

Calling your health care provider

Call your health care provider if you suspect your child may have scoliosis.

References

Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38(4):497-509, vi.

Review Date: 2/27/2008

Reviewed By: Rachel A. Lewis, MD, FAAP, Columbia University Pediatric Faculty Practice, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

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Source Doc: 1_001241

Herniated nucleus pulposus

admin — Wed, 03 Sep 2008 17:49:48 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

A herniated nucleus pulposus is a slipped disk along the spinal cord. The condition occurs when all or part of the soft center of a spinal disk is forced through a weakened part of the disk.

Alternative Names

Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk

Causes, incidence, and risk factors

The bones (vertebrae) of the spinal column run down the back, connecting the skull to the pelvis. These bones protect nerves that come out of the brain and travel down the back and to the entire body. The spinal vertebrae are separated by disks filled with a soft, gelatinous substance, which provide cushioning to the spinal column. These disks may herniate (move out of place) or rupture from trauma or strain.

The spinal column is divided into several segments -- the cervical spine (the neck), the thoracic spine (the part of the back behind the chest), the lumbar spine (lower back), and sacral spine (the part connected to the pelvis that does not move).

Radiculopathy refers to any disease affecting the spinal nerve roots. A herniated disk is one cause of radiculopathy (sciatica).

Most herniation takes place in the lower back (lumbar area) of the spine. Lumbar disk herniation occurs 15 times more often than cervical (neck) disk herniation, and it is one of the most common causes of lower back pain. The cervical disks are affected 8% of the time and the upper-to-mid-back (thoracic) disks only 1 - 2% of the time.

Nerve roots (large nerves that branch out from the spinal cord) may become compressed resulting in neurological symptoms, such as sensory or motor changes.

Disk herniation occurs more frequently in middle aged and older men, especially those involved in strenuous physical activity. Other risk factors include any congenital conditions that affect the size of the lumbar spinal canal.

Symptoms

SYMPTOMS OF HERNIATED LUMBAR DISK

Muscle spasm
Muscle weakness or atrophy in later stages
Pain radiating to the buttocks, legs, and feet
Pain made worse with coughing, straining, or laughing
Severe low back pain
Tingling or numbness in legs or feet

SYMPTOMS OF HERNIATED CERVICAL DISK

Arm muscle weakness
Deep pain near or over the shoulder blades on the affected side
Neck pain, especially in the back and sides
Increased pain when bending the neck or turning head to the side
Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers or chest
Pain made worse with coughing, straining, or laughing
Spasm of the neck muscles

Signs and tests

A physical examination and history of pain may be all that is needed to diagnose a herniated disk. A neurological examination will evaluate muscle reflexes, sensation, and muscle strength. Often, examination of the spine will reveal a decrease in the spinal curvature in the affected area.

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually suggests a herniated lumbar disk.

A foraminal compression test of Spurling is done to diagnose cervical radiculopathy. For this test, you will bend your head forward and to the sides while the health care provider provides slight downward pressure to the top of the head. Increased pain or numbness during this test is usually indicative of cervical radiculopathy.

DIAGNOSTIC TESTS

EMG may be done to determine the exact nerve root(s) that is (are) involved.
Nerve conduction velocity test may also be done.
Myelogram may be done to determine the size and location of disk herniation.
Spine MRI or spine CT will show spinal canal compression by the herniated disk.
Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not possible to diagnosis herniated disk by spinal x-ray alone.

Treatment

The main treatment for a herniated disk is a short period of rest with pain and anti-inflammatory medications, followed by physical therapy. Most people who follow these treatments will recover and return to their normal activities. A small number of people need to have further treatment, which may include steroid injections or surgery.

MEDICATIONS

Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic pain killers will be given to people with a sudden herniated disk caused by some sort of injury (such as a car accident or lifting a very heavy object) that is immediately followed by severe pain in the back and leg.

If the patient has back spasms, muscle relaxants are usually given. On rare occasions, steroids may be given either by pill or directly into the blood through an IV.

NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not respond to anti-inflammatory drugs.

LIFESTYLE CHANGES

Any extra weight being carried by an individual, especially up front in the stomach area, will make back pain worse. Diet and exercise are crucial to improving back pain in overweight patients.

Physical therapy is important for nearly everyone with disk disease. Therapists will tell you how to properly lift, dress, walk, and perform other activities. They will also work on strengthening the muscles of the abdomen and lower back to help support the spine. Flexibility of the spine and legs is taught in many therapy programs.

Some health care providers recommend the use of back braces to help support the spine. However, overuse of these devices can weaken the abdominal and back muscles leading to a worsening of the problem. Weight belts can be helpful in preventing injuries in those whose work requires lifting of heavy objects.

INJECTIONS

Steroid injections into the back in the area of the herniated disk can help control pain for several months. Such injections reduce swelling around the disk and relieve many symptoms. Spinal injections are usually done on an outpatient basis using x-ray or fluoroscopy to identify the area where the injection is needed.

SURGERY

Surgery may be an option for the few patients whose symptoms persist despite other treatments.

Diskectomy removes a protruding disk. This procedure requires general anesthesia (asleep and no pain) and 2-3 day hospital stay. You will be encouraged to walk the first day after surgery to reduce the risk of blood clots.

Complete recovery takes several weeks. If more than one disk needs to be taken out or if there are other problems in the back besides a herniated disk, more extensive surgery may be needed. This may require a much longer recovery period.

Other surgical options include microdiskectomy, a procedure removing fragments of nucleated disk through a very small opening.

Chemonucleolysis involves the injection of an enzyme (called chymopapain) into the herniated disk to dissolve the protruding gelatinous substance. This procedure may be an alternative to diskectomy in certain situations.

Expectations (prognosis)

Most people will improve with conservative treatment. A small percentage may continue to have chronic back pain even after treatment.

It may take several months to a year or more to resume all activities without pain or strain to the back. People with certain occupations that involve heavy lifting or back strain may need to change job activities to avoid recurrent back injury.

Complications

Long-term back pain
Loss of movement or sensation in the legs or feet
Loss of bowel and bladder function
Permanent spinal cord injury (very rare)

Calling your health care provider

Call your health care provider if persistent, severe back pain develops, especially if you have any numbness, loss of movement, weakness, or bowel or bladder changes.

Prevention

Safe work and play practices, proper lifting techniques, and weight control may help to prevent back injury in some people.

Review Date: 5/12/2008

Reviewed By: Thomas N. Joseph, MD, Private Practice specializing in Orthopaedics, subspecialty Foot and Ankle, Camden Bone & Joint, Camden, SC. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Source Doc: 1_000442

Spinal fusion

admin — Thu, 04 Sep 2008 19:02:49 -0700

Overview

Definition
Alternative Names
Description
Indications
Risks
Expectations after surgery
Convalescence
References

Illustrations

Scoliosis

Spinal fusion - series

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Spinal fusion is surgery to correct problems in the spine bones (vertebrae). The surgery stabilizes the back by permanently placing certain bones in the spine together.

Fusing means two bones are permanently placed together so that movement between them can no longer occur.

Spinal fusion is usually done along with other surgical procedures of the spine, such as a diskectomy .

Alternative Names

Vertebral interbody fusion; Posterior spinal fusion; Arthrodesis; Anterior spinal fusion

Description

Spinal fusion surgery uses bone grafts, with or without screws, plates, cages, or other devices. The bone grafts are placed around the problem area of the spine during surgery. As the body heals itself, the graft helps join the bones together.

The most common spinal area treated is the lower (lumbar) spine. However, it can also be done on the upper (cervical) spine.

The procedure is performed while you are under general anesthesia (unconscious and pain-free). The surgeon makes a cut over the area of the spine that will be treated.

If you are having a problem in the lower spine corrected, the repair is done through a surgical cut made directly over the spine. This is called the posterior lumbar approach.

If you are having a problem in the upper spine corrected, the repair is usually done through a surgical cut in the front or side of the neck (anterior cervical spine).

If you are having a problem in the middle spine corrected, the repair is sometimes done through a surgical cut in the chest and abdomen (anterior thoracic spine).

Depending on the reason for surgery, the procedure may involve a combination of surgical cuts.

Indications

Spinal fusion may be recommended for:

Abnormal curvatures, such as those seen with scoliosis or kyphosis
Injury or fractures to the bones in the spine
Herniated disk
Spinal stenosis
Weak or unstable spine caused by infections or tumors

If the pain is persistent and does not respond to other treatments, surgery is considered to relieve the pressure on the nerves.

Surgery is also performed for muscle weakness that does not improve or is getting worse, and for patients having bladder or bowel problems.

Risks

Risks for any anesthesia include the following:

Reactions to medications
Problems breathing

Risks for any surgery include the following:

Bleeding
Infection

Additional risks include the following:

Urinary difficulties (including urinary retention)
Temporarily decreased or absent intestinal function (paralytic ileus)

Expectations after surgery

While many patients have pain relief after surgery, the procedure is not always successful. Back pain sometimes returns, and more than half of patients develop sciatica.

Call your health care provider if persistent, severe back pain develops, especially if you have any numbness, loss of movement, weakness, or bowel or bladder changes.

Convalescence

You will need to stay in the hospital for several days after surgery. The repaired spine should be kept in proper position to maintain alignment. If the surgery involved a surgical cut in the chest, a chest tube may be used to drain fluid build-up. The tube is usually removed after 24-72 hours.

You will be taught how to move properly, how to reposition, and how to sit, stand, and walk. You'll be told to use a "log-rolling" technique when getting out of bed. This means that you move your entire body at once, and not twist the spine.

There is usually considerable pain for the first few days after surgery. You will be given pain medication, perhaps by patient-controlled analgesia (PCA). You may also have a urinary catheter (tube) to collect your urine.

Because of the risk of temporary paralysis after spinal surgery, you may not be able to eat for 2-3 days and will be fed through an IV.

When you leave the hospital, you may need to wear a back brace or cast.

References

Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358:794-810.

Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N EnglJMed. 2008;358(:818-825.

Chou R, Qaseem A, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.

Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38(4):497-509.

A.D.A.M. Copyright

adam.com

Source Doc: 1_002968

Exercise

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

In This Report

Highlights
Introduction
Recommended Exercise Method...
Exercise's Effects on the H...
Exercise's Effects on Diabe...
Exercise's Effects on Bones...
Exercise's Effects on the L...
Exercise's Effects on Weigh...
Exercise's Effects on Other...
Complications
Motivation
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Chronic Conditions and Exercise:

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

Exercise and Smoking:

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

Exercise and Aging:

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

Before and After Exercising:

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

Definitions:

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

Introduction

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

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

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

The benefits of exercise include:

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

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

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

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

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

Recommended Exercise Methods

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

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

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

Click the icon to see how to take a radial pulse

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

There are different types of heart rates.

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

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

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

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

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


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

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

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

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

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

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

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

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

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

Aerobic or endurance
Strength or resistance
Flexibility

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

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

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

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

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

Click the icon to see an image of aerobic exercise.

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

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

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

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

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

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

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

The following are a few observations on specific equipment:

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


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

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

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

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

Click the icon to see an image of cholesterol.

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

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

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

Click the icon to see an image of isometric exercise.

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

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

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

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

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

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

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

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

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

Click the icon to see an image of flexibility exercise.

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

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

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

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

The following tips for exercising may be helpful:

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

Exercise's Effects on the Heart

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Irregular heartbeat
Shortness of breath
Chest pain

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

Click the icon to see an image of stable angina.

Exercise's Effects on Diabetes

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

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

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

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

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

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

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

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

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

Exercise's Effects on Bones and Muscles

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

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

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

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

Click the icon to see an image of osteoporosis.

The following are useful exercises for osteoarthritis patients:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Exercise's Effects on the Lungs

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

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

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

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

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

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

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

Exercise's Effects on Weight

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

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

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

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

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

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

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

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

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

Exercise's Effects on Other Conditions

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

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

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

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

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

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

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

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

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

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

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

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

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

Specific exercises may be particularly beneficial:

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

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

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

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

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

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

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

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

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

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

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

Complications

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

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

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

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

Some people have a higher than average risk for injury:

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

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

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

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

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

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

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

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

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

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

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

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

Anyone who exercises intensely should take the following precautions:

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

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

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

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

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

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

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

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

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

Motivation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resources

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

References

Taylor, A.H., Ussher, M., & Faulkner, G. The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect and smoking behaviour: a systematic review. Addiction. 2007;102:534-543.

Kruk J. Lifetime physical activity and the risk of breast cancer: a case-control study. Cancer Detect Prev. 2007;31(1):18- 28.

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

Adams SA, Matthews CE, Hebert JR, et al. Association of physical activity with hormone receptor status: the Shanghai Breast Cancer Study. Cancer Epidemiol Biomarkers Prev. 2006 Jun;15(6):1170-8.

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

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

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

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

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

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

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

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

Brown SG, Rhodes RE. Relationships among dog ownership and leisure-time walking in Western Canadian adults. Am J Prev Med. 2006 Feb;30(2):131-6.

Simons R, Andel R. The effects of resistance training and walking on functional fitness in advanced old age. J Aging Health. 2006 Feb;18(1):91-105.

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

A.D.A.M. Copyright

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Spinal cord trauma

admin — Wed, 03 Sep 2008 17:54:13 -0700

Overview

Definition
Alternative Names
Causes, incidence, and risk factors
Symptoms
Signs and tests
Treatment
Support Groups
Expectations (prognosis)
Complications
Calling your health care provider
Prevention

Illustrations

Vertebrae

Cauda equina

Vertebra and spinal nerves

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Spinal cord trauma is damage to the spinal cord. It may result from direct injury to the cord itself or indirectly from damage to surrounding bones, soft tissues, and blood vessels.

Alternative Names

Spinal cord injury; Compression of spinal cord

Causes, incidence, and risk factors

Spinal cord trauma can be caused by any number of injuries to the spine. They can result from motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and others.

A minor injury can cause spinal cord trauma if the spine is weakened (such as from rheumatoid arthritis or osteoporosis) or if the spinal canal protecting the spinal cord has become too narrow (spinal stenosis) due to the normal aging process.

Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the disks have been damaged. Fragments of bone (from fractured vertebrae, for example) or fragments of metal (such as from a traffic accident) can cut or damage the spinal cord.

Direct damage can also occur if the spinal cord is pulled, pressed sideways, or compressed. This may occur if the head, neck, or back are twisted abnormally during an accident or injury.

Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or outside the spinal cord (but within the spinal canal). The accumulation of blood or fluid can compress the spinal cord and damage it.

Most spinal cord trauma occurs to young, healthy individuals. Males between ages 15 and 35 are most commonly affected. The death rate tends to be higher in young children with spinal injuries.

Risk factors include participating in risky physical activities, not wearing protective gear during work or play, or diving into shallow water.

Older people with weakened spines (from osteoporosis) may be more likely to have a spinal cord injury. Patients who have other medical problems that make them prone to falling from weakness or clumsiness (from stroke, for example) may also be more susceptible.

Symptoms

Symptoms vary somewhat depending on the location of the injury. Spinal cord injury results in varying degrees of weakness and sensory loss at and below the injury. The pattern depends on whether the entire cord is injured (complete) or only partially (incomplete).

The spinal cord doesn't go below the 1st lumbar vertebra, so injuries at and below this level do not cause spinal cord injury. However, they may cause "cauda equina syndrome" -- injury to the nerve roots in this area.

CERVICAL (NEAR THE NECK) INJURIES

When spinal cord injuries occur near the neck, varying degrees of symptoms can affect both the arms and the legs:

Weakness, paralysis
Breathing difficulties (from paralysis of the breathing muscles)
Spasticity (increased muscle tone)
Sensory changes
Numbness
Pain
Loss of normal bowel and bladder control (such as constipation, incontinence,
bladder spasms)

THORACIC (CHEST-LEVEL) INJURIES

When spinal injuries occur at chest level, varying degrees of symptoms can affect the legs:

Weakness, paralysis
Breathing difficulties (from paralysis of the breathing muscles)
Spasticity (increased muscle tone)
Sensory changes
Numbness
Pain
Loss of normal bowel and bladder control (such as constipation, incontinence, bladder spasms)

Injuries to the cervical or high thoracic cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining regular body temperature.

Signs and tests

Spinal cord injury is a medical emergency requiring immediate attention.

The health care provider will perform a physical exam, including a neurological exam. This will help identify the exact location of the injury, if it is not already known. Some of the person's reflexes may be abnormal or absent. Once swelling goes down, some reflexes may slowly recover.

The following tests may be ordered:

Spine x-rays may show fracture or damage to the bones of the spine.
A CT scan or MRI of the spine may show the location and extent of the damage and reveal problems such as blood clots (hematomas).
Myelogram (an x-ray of the spine after injection of dye) may be necessary in rare cases.
Somatosensory evoked potential (SSEP) testing or magnetic stimulation may show if nerve signals can pass through the spinal cord.

Treatment

A spinal cord trauma is a medical emergency requiring immediate treatment to reduce the long-term effects. The time between the injury and treatment is a critical factor affecting the eventual outcome.

Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression is caused by a mass (such as a hematoma or bony fragment) that can be removed or brought down before there is total destruction of the nerves of the spine, paralysis may in some cases be reduced or relieved. Ideally, corticosteroids should begin as soon as possible after the injury.

Surgery may be necessary. This may include surgery to remove fluid or tissue that presses on the spinal cord (decompression laminectomy). Surgery may be needed to remove bone fragments, disk fragments, or foreign objects or to stabilize fractured vertebrae (by fusion of the bones or insertion of hardware).

Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal.

Anatomic realignment is important. Spinal traction may reduce dislocation and/or may be used to immobilize the spine. The skull may be immobilized with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body).

Treatment will address muscle spasms, care of the skin, and bowel and bladder dysfunction.

Extensive physical therapy, occupational therapy, and other rehabilitation interventions are often required after the acute injury has healed. Rehabilitation assists the person in coping with disability that results from spinal cord trauma.

Spasticity can be reduced by many oral medications, medications that are injected into the spinal canal, or injections of botulinum toxins into the muscles. It is important to treat pain with analgesics, muscle relaxants, or physical therapy modalities.

Support Groups

For organizations that provide support and additional information, see spinal injury resources.

Expectations (prognosis)

Paralysis and loss of sensation of part of the body are common. This includes total paralysis or numbness and varying degrees of movement or sensation loss. Death is possible, particularly if there is paralysis of the breathing muscles.

How well a person does depend on the level of injury. Injuries near the top of the spine result in more extensive disability than injuries low in the spine.

Recovery of some movement or sensation within 1 week usually means the person will eventually recover most function, although this may take 6 months or more. Losses that remain after 6 months are more likely to be permanent.

Complications

Paralysis (paraplegia, quadriplegia)
Loss of sensation
Loss of bladder control
Increased risk of urinary tract infections
Increased risk of chronic bilateral obstructive nephropathy
Loss of bowel control
Loss of sexual functioning (male impotence)
Paralysis of breathing muscles
Increased risk of injury to numb areas of the body
Pain
Complications of immobility:
- Deep vein thrombosis
- Pulmonary infections
- Skin breakdown
- Contractures
Shock
Blood pressure changes - can be extreme
Muscle spasticity

Calling your health care provider

Call your health care provider if injury to the back or neck occurs. Call 911 if there is any loss of movement or sensation. This is a medical emergency!

Management of spinal cord injury begins at the site of an accident with paramedics trained in immobilizing the injured spine to prevent further damage to the nervous system. Someone suspected of having a spinal cord injury should NOT be moved without immobilization unless there is an immediate threat.

Prevention

Safety practices during work and recreation can prevent many spinal cord injuries. Use proper protective equipment if an injury is possible.

Diving into shallow water is a major cause of spinal cord trauma. Check the depth of water before diving, and look for rocks or other possible obstructions.

Football and sledding injuries often involve sharp blows or abnormal twisting and bending of the back or neck and can result in spinal cord trauma. Use caution when sledding and inspect the area for obstacles. Use appropriate techniques and equipment when playing football or other contact sports.

Falls while climbing at work or during recreation can result in spinal cord injuries. Defensive driving and wearing seat belts greatly reduces the risk of serious injury if there is an automobile accident.

Review Date: 7/14/2006

Reviewed By: J.A. Lee, M.D., Division of Surgery, UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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