Back Troubles

Clinical Depression and Pain

2009-11-10T10:46:38+01:00

Clinical Depression and Back Pain

Depression is by far the most common emotion associated with chronic back pain. The type of depression that often accompanies chronic pain is referred to as major depression or clinical depression. This type of depression goes beyond what would be considered normal sadness or feeling "down for a few days".

The symptoms of a major depression occur daily for at least two weeks and include at least 5 of the following (DSM-IV, 1994):

• A predominant mood that is depressed, sad, blue, hopeless, low, or irritable, which may include periodic crying spells
• Poor appetite or significant weight loss or increased appetite or weight gain
• Sleep problem of either too much (hypersomnia) or too little (hyposomnia) sleep
• Feeling agitated (restless) or sluggish (low energy or fatigue)
• Loss of interest or pleasure in usual activities
• Decreased sex drive
• Feeling of worthlessness and/or guilt
• Problems with concentration or memory
• Thoughts of death, suicide, or wishing to be dead

Chronic pain and depression are two of the most common health problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004).

Major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. 32 to 82 percent of patients show some type of depression or depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either depression or chronic back pain alone.

Depression is common for those with chronic back pain

Depression is more commonly seen in patients with chronic back pain problems than in patients with pain that is of an acute, short-term nature. How does depression develop in these cases? This can be understood by looking at the host of symptoms often experienced by the person with chronic back pain or other spine-related pain.

• The pain often makes it difficult to sleep, leading to fatigue and irritability during the day.
• Then, during the day, because patients with back pain have difficulty with most movement they often move slowly and carefully, spending most of their time at home away from others. This leads to social isolation and a lack of enjoyable activities.
• Due to the inability to work, there may also be financial difficulties that begin to impact the entire family.
• Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications.
• The pain is distracting, leading to memory and concentration difficulties.
• Sexual activity is often the last thing on the person’s mind and this causes more stress in the patient’s relationships.
Understandably, these symptoms accompanying chronic back pain or neck pain may lead to feelings of despair, hopelessness and other symptoms of a major depression or clinical depression.

A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including: physical limitation that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses.
Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often led to depression and anger among the back pain patients and to stress and strain in family relationships.

Psychological theories about depression

Several psychological theories about the development of depression in chronic back pain patients focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends.

This situation leads to a downward physical and emotional spiral that has been termed "physical and mental deconditioning" (See Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist.

Diagnosis of Depression and Chronic Back Pain

One of the biggest problems in treating major depression for the patient with chronic back pain is missing the diagnosis. This occurs for two reasons: the chronic back pain patients often do not realize they are also suffering from a major depression, and the doctor is not looking for depression.

Chronic back pain patients will often define their problem as strictly medical and related to the pain. This is supported by a recent study which found that individuals with chronic pain and depression went to their physicians 20% more often than a comparison group of non-depressed medical patients. In addition, depressed chronic back pain patients were 20% less likely to see a mental health specialist than medical patients without a pain problem (Bao, Sturm, & Croghan, 2003).

The depressive symptoms may be downplayed by the chronic back pain patient who believes that, “just get rid of this pain and I won’t feel depressed” or that acknowledging depression is a sign of weakness in dealing with the pain. When the diagnosis of major depression in the chronic back pain patient is missed or ignored, treatments strictly directed at the pain are much more likely to fail.

As concluded by Ohayon and Schatzberg (2003), the presence of a chronic pain physical condition increases the duration of depressive mood, and chronic pain patients seeking medical consultation should be routinely screened for a major depression.

Simultaneous treatment for depression and chronic back pain
Treatment of depression associated with chronic back pain requires a specialized approach. It is generally accepted that the pain and the depression should be treated simultaneously in a multidisciplinary fashion. The treatment of clinical depression most often includes psychological interventions (e.g. counseling, relaxation training, etc) and anti-depressant medication.

In a recent review of the research from 1980 though 2000 that looks at treatment of depression, it was found that the combined treatment approach of medication and psychotherapy yielded better outcomes than either of the interventions alone (Pampallona et al., 2004). Simultaneous treatment directed at the chronic back pain is critical. It has been found that chronic pain may interfere with depression improvement.

Treatment for the chronic pain might include such things as physical rehabilitation aimed at restoration of function, trying to “normalize” one’s life as much as possible even with the pain, appropriate medication management, among other things. Multidisciplinary treatment of the chronic back pain and major depression will ultimately give the patient more of a sense of control over the pain and start a “positive spiral” toward physical and mental re-conditioning.

Further Information about Chronic Pain and Depression can be found at
Click Link: Psychology Today

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Exercising with Osteoporosis

2009-11-04T19:08:32+01:00

If you have osteoporosis, you might mistakenly think exercise will lead to fracture. In fact, though, using your muscles helps protect your bones.

Osteoporosis is a major cause of disability in older women. So if you have osteoporosis, how can you reduce your risk of the spinal problems and broken bones that can result in loss of mobility and independence?

The answer: Exercise.

If you've always been physically active, good for you!

Even though your bones may lose some density as you age, they're less likely to become brittle enough to break if you slip and fall.

But it's not too late to start exercising after menopause, when the pace of bone loss really picks up. Even then, starting an exercise program will increase your muscle strength, improve your balance and help you avoid falls and it may keep your bones from getting weaker.

Other possible benefits of exercise include:
 Increasing your ability to carry out daily tasks and activities
 Maintaining or improving your posture
 Relieving or lessening pain
 Increasing your sense of well-being

The key to exercising with osteoporosis is to find the safest, most enjoyable activities for you, given your overall health and amount of bone loss. There's no one-size-fits-all prescription.

Before you start

Consult your doctor before starting any exercise program for osteoporosis. You may need a bone density test and a fitness assessment first.

In the meantime, think about what kind of activities you enjoy most. If you choose an exercise you enjoy, you're more likely to stick with it over time.

Choosing the right form of exercise

Three types of activities are often recommended for people with osteoporosis:
 Strength training exercises, especially those for the back
 Weight-bearing aerobic activities
 Flexibility exercises

Because of the varying degrees of osteoporosis and the risk of fracture, certain exercises may be discouraged. Ask your doctor or physical therapist whether you're at risk of osteoporosis-related problems, and find out what exercises are appropriate for you.

Strength training

Strength training includes the use of free weights, weight machines, resistance bands or water exercises to strengthen the muscles and bones in your arms and upper spine. Strength training can also work directly on your bones to slow mineral loss.

Osteoporosis can cause compression fractures in your spinal column. These fractures often lead to a stooped posture, increasing the pressure along the front of your spinal column, and result in even more compression fractures. Exercises that gently stretch your upper back, strengthen the muscles between your shoulder blades and improve your posture can all help to reduce harmful stress on your bones and maintain bone density.

Weight-bearing aerobic activities

Weight-bearing aerobic activities involve doing aerobic exercise on your feet, with your bones supporting your weight. Examples include walking, dancing, low-impact aerobics, elliptical training machines, stair climbing and gardening. These types of exercise work directly on the bones in your legs, hips and lower spine to slow mineral loss. They can also provide cardiovascular benefits, which boost heart and circulatory system health.

Swimming and water aerobics have many benefits, but they don't have the impact your bones need to slow mineral loss. However, these activities can be useful in cases of extreme osteoporosis, during rehabilitation following a fracture or for only increasing aerobic capacity.

Flexibility exercises

Being able to move your joints through their full range of motion helps you maintain good balance and prevent muscle injury. Increased flexibility can also help improve your posture. When your joints are stiff, your abdominal and chest muscles become tight, pulling you forward and giving you a stooped posture.

Stretches are best performed after your muscles are warmed up — at the end of your exercise session, for example. They should be done gently and slowly, without bouncing. Avoid stretches that flex your spine or cause you to bend at the waist. These positions may put excessive stress on the bones in your spine (vertebrae), placing you at greater risk of a compression fracture. Ask your doctor which stretching exercises would be best for you.

Movements to avoid

If you have osteoporosis, don't do the following types of exercises:

 High-impact exercises, such as jumping, running or jogging. These activities increase compression in your spine and lower extremities and can lead to fractures in weakened bones. Avoid jerky, rapid movements in general. Choose exercises with slow, controlled movements.
 Exercises in which you bend forward and twist your waist, such as touching your toes, doing sit-ups or using a rowing machine. These movements also put pressure on the bones in your spine, increasing your risk of compression fractures. Other activities that may require you to bend or twist forcefully at the waist are golf, tennis, bowling and some yoga poses.

If you're not sure how healthy your bones are, talk to your doctor. Don't let fear of fractures keep you from having fun and being active.

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Syringomyelia-Spinal Cyst

2009-11-02T13:20:50+01:00

Syringomyelia (sih-ring-go-my-E-lee-uh) is the development of a fluid-filled cyst (syrinx) within your spinal cord.

Over time, the cyst may enlarge, damaging your spinal cord and causing pain, weakness and stiffness, among other symptoms. If left untreated, syringomyelia symptoms may worsen, in some cases requiring surgery.

Syringomyelia has several possible causes. The majority of syringomyelia cases are associated with Chiari malformation, a condition in which brain tissue protrudes into your spinal canal. Other causes of syringomyelia include spinal cord tumours, spinal cord injuries and damage caused by inflammation around your spinal cord.

If syringomyelia isn't causing any problems, monitoring the condition may be all that's necessary. But if you're bothered by symptoms, you may need surgery.

Symptoms of syringomyelia usually develop slowly over time. If your syringomyelia is caused by Chiari malformation — a condition in which brain tissue protrudes into your spinal canal — symptoms may begin during your teenage years or early adulthood. In some cases, a fall, minor trauma, coughing or straining may trigger symptoms of syringomyelia, although none of these causes syringomyelia.

Symptoms:

The following early signs and symptoms of syringomyelia may affect the back of your neck, shoulders, arms and hands first:

 Muscle weakness and wasting (atrophy)
 Loss of reflexes
 Loss of sensitivity to pain and temperature
Other signs and symptoms of syringomyelia may include:
 Stiffness in your back, shoulders, arms and legs
 Pain in your neck, arms and back
 Bowel and bladder function problems
 Muscle weakness and spasms in your legs
 Facial pain or numbness
 A tingling sensation rapidly spreading down your trunk and into your legs when you flex your neck sharply (Lhermitte's sign)

When to see a Doctor:

If you have any of the signs or symptoms associated with syringomyelia, see your doctor. Because many signs and symptoms of syringomyelia can be associated with other disorders, a thorough medical evaluation is important for accurate diagnosis.

If you've experienced a spinal injury, watch carefully for signs and symptoms of syringomyelia. Many months to several years may pass after an injury before syringomyelia develops. If you have syringomyelia symptoms, when you go for an evaluation make sure your doctor knows you had a spinal injury.

Causes:

Although it's unclear exactly how and why it happens, when syringomyelia develops, cerebrospinal fluid — the fluid that surrounds, cushions and protects your brain and spinal cord — collects within the spinal cord itself, forming a fluid-filled cyst (syrinx).

The following conditions and diseases can lead to syringomyelia:

 Chiari malformation — a condition in which brain tissue protrudes into your spinal canal
 Meningitis — an inflammation of the membranes surrounding your brain and spinal cord
 Tethered spinal cord syndrome — a disorder caused when tissue attached to your spinal cord limits its movement
 A spinal cord tumour
 A spine injury

Complications:

In some people, syringomyelia can become a progressive disorder and lead to serious complications. In others, there may be no associated symptoms and no intervention necessary. Complications that may occur as a syrinx grows, or if it damages nerves within your spinal cord, include:

 Scoliosis — an abnormal curve of your spine

 Horner syndrome — a disorder that can occur when the nerves that run from your brain to your eye and face (sympathetic nerve fibers) are damaged, leading to decreased sweating on the side of your face that's affected, a drooping eyelid and a small (constricted) pupil

 Chronic pain

Tests and Diagnosis:

To diagnose syringomyelia, your doctor will begin by asking about your medical history and doing a complete physical examination.

If your doctor suspects syringomyelia, you'll likely undergo a magnetic resonance imaging (MRI) scan of your spine and spinal cord. An MRI is the most reliable tool for diagnosing syringomyelia.

Using magnetic fields and radio waves, an MRI produces 3-D, high-resolution images of your spine and spinal cord. If a syrinx has developed within your spinal cord, your doctor will be able to see it on an MRI. A dye or contrast medium can be injected for the test, and once it travels to your spine, it can enhance the MRI images. An MRI is a safe and painless test. Over time, repeat MRIs can be used to monitor the progression of syringomyelia.

In some cases, syringomyelia may be discovered incidentally when a spine MRI or computerized tomography (CT) scan is done for other reasons.

Treatments and Medications:

Treatment for syringomyelia depends on the severity and progression of your signs and symptoms.

Monitoring

If syringomyelia is discovered on an MRI scan that's done for an unrelated reason, and it's not causing signs or symptoms, monitoring with periodic MRI and neurological exams may be all that's necessary. In rare cases, a syrinx may resolve on its own without treatment.

Surgery

If syringomyelia is causing signs and symptoms that interfere with your daily life, or if signs and symptoms rapidly worsen, surgery is usually recommended. The goal of surgery is to remove the pressure the syrinx places on your spinal cord and to restore the normal flow of cerebrospinal fluid. The type of surgery you'll need depends on the underlying cause of syringomyelia.

Typically, surgery for syringomyelia includes one or more of the following:

 Treating Chiari malformation. If syringomyelia is caused by Chiari malformation, your doctor may recommend surgery that involves enlarging the opening at the base of your skull (suboccipital craniectomy) and expanding the covering of your brain (dura). This surgery can reduce pressure on your brain and spinal cord, restore the normal flow of cerebrospinal fluid and, in most cases, resolve syringomyelia.

 Draining the syrinx. To drain the syrinx, your doctor may surgically insert a drainage system, called a shunt. It consists of a flexible tube with a valve that keeps fluid from the syrinx flowing in the right direction. One end of the tubing is placed in the syrinx, and the other is placed just outside your spinal cord. The shunt remains inside your spine after surgery. In some cases, your doctor may be able to drain the syrinx during surgery with a small tube (catheter), and a shunt is not required.

 Removing the obstruction. If something within your spinal cord is hindering the normal flow of cerebrospinal fluid, such as a tumour or a bony growth, surgically removing the obstruction may restore the normal flow and allow fluid to drain from the syrinx.

 Correcting the abnormality. If a spinal abnormality is hindering the normal flow of cerebrospinal fluid, surgery to correct it — such as a releasing a tethered spinal cord — may restore normal fluid flow and allow the syrinx to drain.

Surgery doesn't always effectively restore the flow of cerebrospinal fluid, and the syrinx may remain, despite efforts to drain the fluid from it.

Follow Up:

Follow-up care after surgery is critical because syringomyelia may recur. You'll need regular examinations with your doctor, including periodic MRI tests, to assess the outcome of surgery. Other syrinxes may form, requiring additional surgery. Even after treatment, some signs and symptoms of syringomyelia may remain, as a syrinx can cause permanent spinal cord and nerve damage.

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Coping With Muscle Spasm

2009-10-31T17:22:53+01:00

* Pain and stiffness that doesn’t ease up within the first three days.

* If a back or neck spasm is accompanied by tingling, numbness or weakness, see your GP immediately.

What Your Symptom Is Telling You

You bend down to pick up a piece of paper off the floor. You cradle the phone with your chin while chatting. You hoist your groceries out of your car boot. Suddenly, you're ambushed by a tightness that painfully twists your body like a corkscrew.

When a muscle goes into spasm, all the fibres within the core of a muscle contract simultaneously. This most commonly occurs when you suddenly move or overextend a tensed-up muscle that hasn't been properly prepared for the movement.

Quickly bending over after sitting, for example, can overstretch your back muscles and injure the area. In response, the surrounding muscle fibres instantly tighten, forming a kind of protective splint that guards the back against further irritation.

This triggers a back-stabbing cycle: Contracted fibres squeeze off blood flow to the muscle, creating irritation and more pain. The additional pain triggers even tighter contractions. You're caught in a painful vice without a chance of the muscle relaxing on its own.

Unlike an ordinary muscle cramp that also involves a sudden contraction, a spasm does not usually release with movement. If your back locks in spasm, you can't move.

The prime targets for spasms are the muscles in the neck and back. These areas are often tight, tense and more vulnerable to becoming overstressed by the least little thing. A cool breeze, for example, might blow over neck muscles already tensed from working at a computer or playing tennis. These muscles suddenly clench against the chill.

Now you have the classic "crick" and probably won't be able to turn your head to see out your car's side window.
A sudden spasm in your back or neck that's accompanied by numbness, tingling or weakness, could mean a ruptured disk or nerve injury.

Symptom Relief

Spasms have a way of holding on stubbornly. To release that grip, try any of these techniques.

Get off your feet. "Lying down will take the strain off already stressed tissues." If the spasm is in your back, gently bring your knees up to your chin and hold them there for a minute or more (as long as there is no pain). "This should help release some of the shortened connective tissue and muscle fibres."

Try a gentle ice massage. "Rubbing an ice cube directly over the sore area in slow circles can numb the area in about five minute’s flat." (If you can't reach the area yourself, ask a friend or family member to lend a hand.) What's more, at first the ice narrows the blood vessels, then they open up super wide. This allows a rush of healing blood to flow in, helping to release the clenched fibres. "Just be sure to keep the ice moving so you don't freeze and injure surface tissues." Repeat the rub once an hour.

Swallow a pain reliever. Aspirin or another no steroidal anti-inflammatory such as ibuprofen are "the best pain relievers you can get without a prescription." Acetaminophen may bring less effective relief because it's not an anti-inflammatory.

Limber gently; don't jerk. After icing, moving slowly and gently will help restore normal circulation and ease fibres back into their customary patterns of contraction and relaxation. Don't stretch too aggressively, however. "Stretching could make the spasm worse."

After icing your sore shoulder, for example, simply move it through its full range of motion. Do this by gently raising your shoulders up to your ears, rolling them forward, then back, and also moving your arm diagonally across your chest. "This actually reprograms the fibres in the shoulders, telling them where to go so they don't clench up again."

Get it warm. If the spasm still has you in its grip after three days, you can try treating the area with heat. Once the acute pain and swelling subside, heat will nudge blood flow to the sore site. Simply wrap a hot, wet towel around the area, cover it with plastic wrap and then wrap it with a dry towel to seal in the heat. Apply these hot packs five times a day for no more than 20 minutes at a time.

Break up the knot. Once the pain and swelling have subsided somewhat, you may be left with a tough little knot of muscle that is still in spasm. Try pressing your thumb, finger or even the tip of a broom handle directly into a stubborn spasm. This may help move the built-up fluid, relax the muscle and separate fibres. If direct pressure doesn't do the trick, you may need to see a Practitioner who specializes in musculoskeletal pain.

Comments

Cervical Lordosis

2009-10-16T15:35:46+02:00

David from Kintbury:

Q: My MRI showed loss of normal cervical lordosis in C3-C-7. Is it normal for my fingers to tingle?
and feel numb at the tips? At first the numbness was in my thumb and now it's all finger and runs up my arm. I have been able to deal with the pain in my neck as long as I take mobic daily (anti-inflamatory) lifting something as simple as a gallon of milk is very painful. What can this be?

Answer:Yes it is...
The primary symptom of cervical radiculopathy is pain radiating into the arm, neck, chest, and/or shoulders. Numbness or tingling in fingers or hands may also be present, as well as muscle weakness. Other symptoms may include lack of coordination, particularly in the hands.

Radiculopathy refers to disease of the spinal nerve roots (from the Latin radix for root). Radiculopathy produces pain, numbness, or weakness radiating from the spine.

Description

At the joints between the vertebrae, sensory nerves (nerves conducting sensory information toward the central nervous system) and motor nerves (nerves conducting commands to muscles away from the central nervous system) connect to the spinal cord. Each spinal nerve divides or fans out just before merging with the spinal cord. These smaller, separate nerve bundles are termed the roots of the nerve because they are reminiscent of the way the roots of a plant divide in the ground.

Damage to the spinal nerve roots can lead to pain, numbness, weakness, and paresthesia (abnormal sensations in the absence of stimuli) in the limbs or trunk. Pain may be felt in a region corresponding to a dermatome, an area of skin innervated by the sensory fibers of a given spinal nerve or a dynatome, an area in which pain is felt when a given spinal nerve is irritated. Dynatomes and dermatomes may overlap, but do not necessarily coincide.

Radiculopathies are categorized according to which part of the spinal cord is affected. Thus, there are cervical (neck), thoracic (middle back), and lumbar (lower back) radiculopathies. Lumbar radiculopathy is also known a sciatica. Radiculopathies may be further categorized by what vertebrae they are associated with. For example, radiculopathy of the nerve roots at the level of the seventh cervical vertebra is termed C7 radiculopathy; at the level of the fifth cervical vertebra, C5 radiculopathy; at the level of the first thoracic vertebra, T1 radiculopathy; and so on.

Radiculopathy is to be distinguished from myelopathy, which involves pathological changes in or functional problems with the spinal cord itself rather than the nerve roots. Sometimes, radiculopathy is also distinguished from radiculitis, the latter being defined as irritation (hence the "itis" suffix) of a nerve root that causes pain in the dermatome or dynatome corresponding to that nerve. Radiculopathy, on the other hand, denotes spinal nerve dysfunction (not just irritation) presenting with pain, altered reflex, weakness, and nerve-conduction abnormalities. Pain may not be present with radiculopathy, but is always present with radiculitis.

Millions of persons experience some form of radiculopathy at some point in their lives. Because many of the causes of radiculopathy are long-term diseases (e.g., ankylosing spondylosis, diabetes) or diseases that tend to affect the elderly (e.g., arthritis), radiculopathy occurs more often in the middle-aged and elderly than in the young. However, injuries due to sports, heavy lifting, or bad posture affect the young as well. Cervical disc herniation with radiculopathy (mostly involving the C4 to C5 levels) affects 5.5 per 100,000 adults every year, with the highest risk being for adults 35 to 55 years year old.

Causes and symptoms

Radiculopathy can be caused by any disease or injury process that compresses or otherwise injures the spinal nerve roots. Violent blows or falls, cancer, some infections such as flu and Lyme disease, diseases that lead to degeneration of the vertebrae and/or intervertrebral discs (osteoarthritis), slipped or herniated discs, scoliosis, and other factors can cause radiculopathy. For example, extreme backward bending of the neck can trigger cervical radiculopathy. This has given rise to a recently-recognized category of radiculopathy termed "salon sink radiculopathy," so-called because salon patrons are asked to tip their heads sharply backward into sinks for shampooing. Spondylosis (immobilization and growing-together of one or more vertebral joints, often due to osteoarthritis) can deform the structures of bone, cartilage, and ligament through which spinal nerves must pass, leading to cervical and lumbar radiculopathy. Thoracic and lumbar radiculopathies are a common result of diabetes, which can impair blood flow to the spinal nerve roots.

Diagnosis

Radiculopathy is a possible diagnosis when numbness, pain, weakness, or paresthesia of the extremities or torso are reported by a patient, especially in a dermatomal pattern. However, these symptoms can also be caused by nerve compression remote from the spine, and the physician must rule out this possibility before ruling in favor of radiculopathy. Electrodiagnostic studies can help distinguish radiculopathy from other diagnoses. These techniques include current perception threshold testing, which tests patient ability to sense alternating electric currents at several frequencies; electromyographic nerve conduction tests; and testing of sensory evoked potentials (changes in brain waves in response to sensory stimuli).

When radiculopathy is diagnosed, the location of the affected nerve roots and, ultimately, the cause of their dysfunction must be determined. Diagnosticians look at the precise features of radicular symptoms in order to determine the spinal level of the affected root or roots. For example, radiculopathy at the C7 level (the nerve root most often affected by herniated cervical disc) is characterized by weak triceps and wrist extensor muscles and a numb middle finger. Radiculopathy at the L3 (third lumbar disc) level is characterized by decreased patellar (kneecap) reflex, loss of sensation and/or pain in the anterior (forward) part of the thigh, and weakness in quadriceps muscle; and so on.

X ray or MRI may be used to confirm the diagnosis. A herniated disc, for example, will be revealed by imaging. A herniated disc is one that has partly popped or bulged out from between the vertebra above and below it. This may place pressure on the nerve roots and on the spinal cord itself.

In persons with spinal cancer or other progressive disorders, the appearance of radiculopathy may be an important sign that pressure is beginning to be exerted by the tumour or some other changing structure. This may signal that it is time for surgical intervention.

Treatment

Treatment for radiculopathy varies with the nature and severity of the disease process or injury that has caused the disorder. Conservative (non-surgical) treatment is often attempted first. This consists primarily of rest, exercise, and medication. Patient-specific exercises are prescribed by a physical therapist for the targeted strengthening of muscles and other supporting tissues to relieve pressure on affected spinal nerve roots. Weight loss may be advised to decrease stress on the spine. Medications may include oral opioids (e.g., morphine) or other analgesic (anti-pain) medications. In severe cases, injection of an opioid by an external or implanted pump directly into the affected area may be prescribed. Epidural corticosteroid injections, selective nerve root block, and epidural lysis (destruction) of adhesions are also used to treat radiculopathy. A soft neck collar may be prescribed for persons with cervical radiculopathy.

When conservative treatment fails, surgery may be necessary. The primary purpose of surgery is to take pressure off of affected nerve roots or the blood vessels that serve them and to stabilize spinal structure, but surgery may also sever nerves in order to relieve severe pain. Fusion of vertebrae (i.e., removal of the flexible intervertebral disc and joining of the adjacent vertebrae so that they grow into a single bone) was for many decades a common treatment for intractable radiculopathy.

The Bryan Disc

The Bryan disc is a flexible disc or ring of titanium and Teflon that is used to replace the intervertebral disc in patients with degenerative disc disease. Two versions of the disc, one cervical (for the neck) and the other lumbar (for the lower back) were under development. Early reports from surgeons were positive. The advantage of such an implant over fusion is that the patient does not lose flexibility in that part of their spine.

Recovery and rehabilitation

Exercise is key to the treatment of both conservative and surgical treatment of radiculopathy. It may even be curative in some cases. It is also an important aspect of recovery from surgery. Exercise is done as directed by a physical therapist.

Prognosis

Prognosis varies with the underlying process causing the radiculopathy. For sports injuries, at one extreme, the prognosis is excellent; for degenerative disc disorders, even surgery may not completely or permanently resolve the problem. However, new surgical techniques are improving this picture.

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Osteoporotic Fracture Treatment Options

2009-10-15T10:26:00+02:00

Introduction

First the good news, osteoporosis is a condition that is both preventable and treatable if caught in time. However, the bad news is that there is not enough awareness of the opportunities for prevention and treatment of osteoporosis, and too many people mostly women over the age of 50 suffer significant illness, deformity and sometimes death from this condition.

Osteoporosis itself does not cause back pain. However, osteoporosis can weaken the vertebral body (spine) so that it can no longer withstand normal stress or a minor trauma (e.g. a fall), resulting in a fracture. In fact, a fracture is typically the first outward sign of the disease, and advanced osteoporosis is potentially very painful and disabling.
Osteoporosis—the loss of calcium from bones resulting in weakened bone structure—increases the risk of fracture of vertebral body (the thick block of bone at the front of the vertebrae).

In this type of fracture, the top of the vertebral body collapses down with more collapse in front thus producing the "wedged" vertebrae, the "dowagers" hump and shortened height.
The resulting change in height and spinal alignment can lead to serious health problems, including:

•Chronic or severe pain
•Limited function and reduced mobility
•Loss of independence in daily activities
•Decreased lung capacity
•Difficulty sleeping

Also, studies show that a first osteoporotic fracture makes it five times more likely further fractures will occur. That is why it is important that patients seek medical treatment for osteoporosis before it reaches the fracture stage.

Kyphoplasty compared with Vertebroplasty

Vertebroplasty and Kyphoplasty are both minimally invasive surgical procedures for treating osteoporotic fractures where a cement-like material is injected directly into the fractured bone. This stabilizes the fracture and provides immediate pain relief in many cases.

Kyphoplasty includes an additional step. Prior to injecting the cement-like material, a special balloon is inserted and gently inflated inside the fractured vertebrae. The goal of this step is to restore height to the bone thus reducing deformity of the spine. Most patients return to their normal daily activities after either procedure.

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Smoking Can Cause Back Pain!

2009-10-14T17:44:21+02:00

About 8,000,000 people in the UK are said to suffer from some type of arthritic pain At any one time. About 6 million people suffer from back pain in the UK. Each year approximately 2 million people are said to be functionally disabled from back pain.

In the U.K., £5 billion is annually spent on back pain treatment. £18 billion is lost annually in productivity and wages as a result of back pain. These commonly quoted statistics, even if partially accurate, indicate a devastating problem for the United Kingdom. It should be said at this point that statistically, the same ratios of occurrence to gross population may be representative of what goes on in other industrialised nations.

As we all know nutrition is a really important component of our overall health including the health of our back.
Those of us who enjoy too many calories and eat relatively unhealthy foods are more than likely to be a bit heavier than we would like to be!

So common sense should tell us that the more we weigh the more stress is placed on our spine as well as other joints in our bodies which causes extra wear and tear.

So what about the effects of smoking?

If you smoke you probably do not want to hear this, but research shows that there is a direct relationship between smoking cigarettes and having back related problems.

You see smoking slows down your circulation and cuts down the oxygen supply in your bloodstream. A healthy blood and oxygen supply is vital for good health and for proper healing to occur.

*According to a recent study conducted by Georgetown University scientist David Lanier, smoking is a major risk factor in the development of acute lower back pain, an ailment that ranks second only to common colds!

How could smoking cause back pain?

Scientists aren't sure why some smokers are prone to back pain. According to the report in the Annals of the Rheumatic Diseases, nicotine from cigarettes "could affect the manner in which the brain processes sensory stimuli and the central perception of pain"- in other words, cigarettes affect the way the brain sends its pain signals. Smoking may also damage tissue in the lower back and elsewhere in the body by slowing down circulation and reducing the flow of nutrients to joints and muscles, according to the journal.

Should I give up smoking for the sake of my back?

The data may still be a little fuzzy, but the message is clear. As reported in the BMJ, smokers who suffer from back pain have every reason to kick the habit. Giving up cigarettes probably won't immediately banish back pain, but it just might help. Of course, quitting smoking will also dramatically lower the risk of heart disease, cancer, and a host of other diseases.

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Question: What is a Bulging Disc?

2009-10-13T15:00:47+02:00

Answer: An intervertebral disc bulge occurs when the inner jelly substance pushes on the outer wall of the disc but doesn't completely go through the outer wall. The degree of pain and the limitation of pain free movement is dependent on the amount of pressure the bulge is putting on the nerve. A disc bulge is measured in millimetres and can be identified by both x-ray and magnetic resonance imaging (MRI).

If you suspect that you have a bulging disc, you will need to see a physician and get a full evaluation including an x-ray or MRI. Make sure the doctor also assesses you from a physical perspective to clinically identify any physical dysfunctions.

There are a variety of treatment options available for a bulging disc but the most powerful one is to identify the muscle imbalances responsible for your physical dysfunctions, dysfunctions that are the true root cause of your bulging disc.

Now let us come to the vital part of our discussion which is regarding bulging disc treatment. Treatment would depend on the severity of the condition; the doctor only in very rare cases will progress towards surgery. Generally the doctor asks the patient to take some rest and strictly avoid those things that can trigger the pain, also it is imperative to mention here that a prolonged rest can only deteriorate your condition, so be careful.

Medications that are generally given are the non-steroidal anti inflammatory drugs. Analgesics, muscle relaxants, even narcotics medications are prescribed sometimes, but before using any of the medication, always consult the doctor.

Another bulging disc treatment you can try out is cold ice and hot packs, both of them used according to one's condition can yield helpful results. A little bit of physical exercises like stretching ones. Yoga, walking, meditation can help you greatly.

The last and perhaps the best bulging disc treatment is surgery, if everything fails, the doctor uses it as a last weapon. But here the patient must be both mentally and physically prepared to face the surgery and also the situation after a surgery.

Comments

Coping with Neck and or Upper Back Pain.

2009-10-09T16:24:00+02:00

When it comes to assessing back pain, the upper back and neck region is the most complex area of our body because of the many joints and how those joints work together.
The neck and shoulders can exhibit much the same difficulties as the lower back, such as pulled muscles, disc problems, arthritis, and other issues. While lower back pain affects our ability to ambulate, upper back pain affects our ability to perform daily activities like brushing our teeth or driving a car.

What can cause it?

The two most common reasons for upper back and neck pain are trauma and muscle imbalances, the latter being responsible for what are called "postural dysfunctions." These postural dysfunctions cause abnormal alignment of the head and shoulders and abnormal positioning of the joints that lead to increased wear and tear on the joints, muscles, and ligaments even discs.

The most important thing to understand about any upper back and neck pain is that, barring trauma, these conditions do not happen overnight. You may be come symptomatic very quickly, but it takes a long time for the condition whatever it might be, to become painful.

How is my condition diagnosed?

Your condition can be diagnosed by a GP, a physical therapist, Osteopath or a chiropractor. But in order to get the most comprehensive picture of your condition, you may need to see more than one professional.

What are the symptoms?

The majority of the complaints range from local pain to radiating pain, weakness and pain in the arms, pain and irritation with any movement of the upper body, morning pain and stiffness.

What are my treatment options?

Cortisone injections, prescriptions for muscle relaxants or non-steroidal anti-inflammatory drugs (NSAIDs), and bed rest are most commonly employed.

Osteopathy, Chiropractic care and physical therapy can offer spinal mobilizations, hot packs, ultrasound, electrical stimulation, cervical traction, and therapeutic exercises.

Surgery should always be your last option and should only be considered if the severity of your condition warrants it.

Why do traditional treatments fail?

Most traditional treatments fail because they simply address the symptoms and fail to address the cause of the condition. Your pain is a physical problem and it requires a physical solution. There are no pills or injections that can create postural balance in your body, which is necessary to take the pressure off the nerve or make the joints work better.

Which treatments work best?

The principles of Muscle Balance Therapy address your pain and also pinpoints what is responsible for your condition in the first place.

Through strategic bodily assessments, your individual muscle imbalances can be identified, and a targeted corrective program can be designed for your specific needs. The ultimate goal is to achieve a more balanced body and take the stress off the muscles, joints, and ligaments.

Comments

Childhood Obesity & Back Pain

2009-10-07T17:51:38+02:00

There is continued concern over the levels of obesity among children in the UK. Obesity during childhood is a health concern in itself, but can also lead to physical and mental health problems in later life, such as heart disease, diabetes, osteoarthritis, back pain, increased risk of cancer, low self-esteem and depression. Obesity develops as a result of an imbalance between energy consumption and energy expenditure.

Measuring Obesity in Children

Body Mass Index (BMI) is one of the most widely used methods for assessing body composition or estimating levels of body fat. BMI is calculated by dividing an individual's weight (in kilograms) by their height (in meters) squared and gives an indication of whether weight is in proportion to height. In adults there are static cut off values for BMI between normal weight, overweight and obesity; however these are not appropriate for children. The normal BMI range for children changes substantially with age and is different between boys and girls.

A certain BMI at one age may be the norm but at another age the same BMI may be unusually high or low. Interpretation of BMI values in children therefore depends on comparison with age- and sex-specific growth reference charts. These provide thresholds or cut-off points in the BMI distribution (BMI centiles), which can be used to estimate levels of obesity, overweight and underweight in children. Statistics in this release were derived using the UK 1990 growth reference for BMI (the standard approach in the UK).

The BMI centile cut-offs used to derive the percentages classified as overweight, obese and severely obese are those recommended for the purposes of population monitoring and epidemiological research. The statistics do not represent the percentage of children clinically classified as overweight, obese or severely obese. Use of the cut-offs recommended for clinical practice would result in lower percentages for overweight, obese and severely obese and BMI centile would be only one of a variety of factors taken into consideration before any clinical diagnosis is made.

The release updates annual statistics on high and low body mass index (BMI) for Primary 1 school children, and includes data to school year 2007/08. The statistics are derived from height and weight measurements recorded at routine health reviews for ten NHS Boards in Scotland which participate in the CHSP-School system. Statistics are presented by: participating NHS Board, Council Area, Community Health Partnership, gender and UK Index of Multiple Deprivation (SIMD) quintile.

KEY POINTS

Based on centile cut-offs on the 1990 UK growth reference charts used for population monitoring purposes:

•In 2007/08, among the ten participating NHS Boards, 20.0% of Primary 1 children were classified as overweight, including 7.9% obese and 3.9% severely obese.

As the number of NHS Boards submitting data has increased since 2000/01 (from four to ten Boards) the trend for ‘All participating NHS Boards’ should be interpreted with a degree of caution. However, a similar trend is observed among the Boards participating throughout the eight year period.

INTERPRETATION

Statistics in this release are derived from centiles, using the 1990 UK growth reference standards. These growth reference charts are based on data collected between 1978 and 1990 from UK surveys (they therefore represent children's weight relative to height before the recent rise in levels of obesity in children). Cut-off points for population monitoring purposes, based on these studies, define overweight as children whose BMI is in the top 15% of the UK 1990 reference range for their age and sex.

Obese and severely obese children are defined as those whose BMI is in the top 5% and 2% of the reference range respectively. Children with a BMI within the 5th - 85th centile range are considered to be in the normal range (although BMI may incorrectly categorize a small minority of children with heavy musculature as being overweight or obese). These statistics classify underweight and very underweight as children with a BMI in the bottom 5% and 2% of the reference range respectively.

All NHS Boards in the UK provide a Child Health Surveillance Programme where children are offered routine reviews at various stages of their life. The majority of Boards record these reviews using the Child Health Systems Programme (CHSP). Statistics in this release are derived from height and weight measurements collected at routine health reviews in Primary 1 through the CHSP-School system. As CHSP-School is implemented in the majority of NHS Boards, data from this system can be used to estimate prevalence of over- and under- weight children in Scotland.

Data for NHS Grampian, NHS Orkney, NHS Shetland, NHS Highland and the former NHS Greater Glasgow are not included. The BMI statistics cover approximately 88% of children in Primary 1 among the ten participating NHS Boards, and approximately 52% of children in Primary 1 across Scotland.

Figures for Community Health Partnerships, Council Areas and NHS Boards with small numbers of reviews should be interpreted with care as the small numbers may result in fluctuations in the percentages from year to year etc. The smaller the number of reviews, the poorer the precision of the estimate (percentage) and the wider the associated confidence interval.

DETAILED FINDINGS

Based on centile cut-offs on the 1990 UK growth reference charts used for population monitoring purposes:

•In 2007/08, among the ten participating NHS Boards, 20.0% of Primary 1 children were classified as overweight, including 7.9% obese and 3.9% severely obese.

•Levels of high BMI increased slightly, and very gradually, between 2000/01 and 2005/06. Over the last two years, levels of high BMI have decreased slightly and the percentages for 2007/08 are similar to those for 2000/01 (19.7% overweight, including 8.0% obese and 3.9% severely obese). As the number of NHS Boards submitting data has increased since 2000/01 (from four to ten Boards) the trend for ‘All participating NHS Boards’ should be interpreted with a degree of caution. However, a similar trend is observed among the Boards participating throughout the eight year period.

•In Primary 1, levels of high BMI amongst boys tend to be slightly higher than those for girls. In school year 2007/08, 20.5% of boys were classified as overweight (including 8.2% obese and 4.1% severely obese) compared to 19.6% of girls (including 7.6% obese and 3.6% severely obese).

•Primary 1 figures for 2007/08 indicate that the most deprived areas have the highest percentage of children classified as overweight, obese and severely obese (21.7% overweight, including 9.2% obese and 4.5% severely obese) while the least deprived areas had the lowest percentage (18.1% overweight, including 6.3% obese and 3.0% severely obese), however this pattern is not clearly observed for all previous years.

•The percentage of Primary 1 school children with low BMI (classified as underweight) was 3.2% in 2007/08. Levels of low BMI have remained relatively stable at around 3% in recent years.

Development of Obesity

Industrialization and modernization has had a tremendous impact on our food. For example, food can be purchased just about anywhere. No longer is it necessary to expend physical effort to hunt and forage for food. There are vast numbers of processed food products available and labour-saving devices (e.g., microwave ovens) to cook food. The market for many convenience foods and kitchen devices came about when women entered the work force.

Childhood obesity is on the rise due to many factors that include sedentary behaviour (e.g., computer games), eating when not hungry, television advertising high-calorie 'tasty' foods, and even genetics.

According to the Department of Heath "Call to Action to Prevent and Decrease Overweight and Obesity," 40% of adults in the United Kingdom do not participate in any leisure-time physical activity and less than 1/3 engage in at least 30 minutes of physical activity most days.

Another consideration is where meals are eaten. In 1992, 38% of the food pounds were spent on foods eaten away from home. It can be difficult to control what you eat and how the food is prepared (e.g., fried versus broiled) at a restaurant; especially 'fast food' establishments.

If you are overweight, obese, or working at maintaining a healthy weight, there are many tools available to empower your efforts.

Comments

What is Spinal Arthritis?

2009-10-06T06:42:39+02:00

Spinal Arthritis can be a very painful and debilitating condition that often affects individuals 40 or older.

If left untreated, it can lead to physiological problems such as muscle breakdown or weakness, as well as psychological problems such as anxiety and depression. Sometimes, a person with arthritis of the spine can suddenly suffer excruciating pain that will keep him or her bedridden and unable to perform normal daily activities.

What causes it?

In a word: imbalances. These imbalances can occur in your stress levels, hormone levels, and nutritional levels. Muscle imbalances can adversely affect posture, which can lead to neck and back pain. The causes may vary from one person to the next, but usually degeneration in the bones along with calcium build-up are factors. Sometimes past injuries or surgeries are to blame. Nerves become pinched or compacted, causing severe pain or numbness in the affected areas. Many who suffer from arthritis of the spine will also be affected by herniated discs and bone spurs.

What are the symptoms?

Classic symptoms include pain and numbness in the back, neck, head, and shoulders. Symptoms may be different for different people, and the frequency and intensity will also vary. Some areas may ache from time to time and be all right other times. Bending and other everyday movements may also cause pain. Numbness is the neck area is very common, although other areas, including the arms and legs, may also experience numbness. In some cases, frequent urination or the urgent need to urinate may occur.

How is the condition diagnosed?

You will need to go over your medical history with a doctor and undergo a physical examination. During the physical examination, you will likely be asked to do a few simple exercises so that your GP can see if your range of motion has been affected. These may include bending forward, side-to-side, or backwards. You also may be asked to lie down and raise your legs. Let your GP know if any of these movements causes pain. Because symptoms of arthritis of the spine are similar to other spinal conditions, it is important for your GP to rule out other - possibly more serious - problems. To do this, you may need to undergo a variety of tests such as blood tests and x-rays.

What are the most common treatments?

A common treatment is to restrict movement of the neck and back with a cervical collar or other bracing. If your condition does not improve after this kind of treatment, surgery may be an option. Commonly used drugs include acetaminophen (Tylenol), non-steroidal anti-inflammatory drugs (NSAIDs) ibruprofen, and opiods such as codeine and morphine. Non-drug treatments include hot packs, ultrasound, electrical stimulation, and therapeutic exercises. Stimulating blood flow using massage or a hot tub may also help. Alternative treatments include yoga and relaxation therapy.

Why do traditional treatments fail?

Most traditional treatments fail to provide long-term relief because they merely address the symptoms and fail to address the cause of the condition. Unless the cause is fully understood, trying to get rid of the problem becomes a guessing game. One thing is certain: No treatment has been found to be the "one thing that works for everyone."

Which treatments work?

Because Arthritis of the spine is a degenerative process combining various treatment approaches is critical to achieving sustainable results...
•Inversion Therapy can help with decompression and stress on the joints of the spine...
•Muscle Balance Therapy can help generate balance and stability in the pelvis and spine and minimize excessive wear and tear of the disc and other joints of the spine.
•Daily Trigger Point Therapy can help restore proper muscle function and address localized pain.
•Healing Heat is far different then the heat you are used to, it is deep penetrating and longer lasting for relief of pain and increase in joint range of motion.

Comments

Back Pain – A Guide towards Differential Diagnosis

2009-10-05T10:39:34+02:00

Back pain affects an estimated 80% of the population at some stage in their lives; in fact, it’s the second leading reason after the common cold for lost time from work. Although this symptom may herald a spondylogenic disorder, it may also result from a genitourinary, GI, cardiovascular, or neoplastic disorder. Postural imbalance associated with pregnancy may also cause back pain.

The onset, location, and distribution of pain and its response to activity and rest provide important clues about the cause. Pain may be acute or chronic and constant or intermittent. It may remain localized in the back or radiate along the spine or down one or both legs. Pain may be exacerbated by activity usually, bending, stooping, or lifting and alleviated by rest, or it may be unaffected by either.

Intrinsic back pain results from muscle spasm, nerve root irritation, fracture, or a combination of these mechanisms. It usually occurs in the lower back, or lumbosacral area. Back pain may also be referred from the abdomen or flank, possibly signalling a life-threatening perforated ulcer, acute pancreatitis, or dissecting abdominal aortic aneurysm.

Emergency interventions
If the patient reports acute, severe back pain, quickly take his vital signs; then perform a rapid evaluation to rule out life-threatening causes. Ask him when the pain began. Can he relate it to any causes? For example, did the pain occur after eating? After falling on the ice? Have the patient describe the pain. Is it burning, stabbing, throbbing, or aching? Is it constant or intermittent? Does it radiate to the buttocks or legs? Does he have leg weakness? Does the pain seem to originate in the abdomen and radiate to the back? Has he had a pain like this before? What makes it better or worse? Is it affected by activity or rest? Is it worse in the morning or evening? Does it wake him up?

Typically, visceral-referred back pain is unaffected by activity and rest. In contrast, spondylogenic-referred back pain worsens with activity and improves with rest. Pain of neoplastic origin is usually relieved by walking and worsens at night. If the patient describes deep lumbar pain unaffected by activity, palpate for a pulsating epigastric mass. If this sign is present, suspect dissecting abdominal aortic aneurysm. Withhold food and fluid in anticipation of emergency surgery. Prepare for I.V. fluid replacement and oxygen administration.

If the patient describes severe epigastric pain that radiates through the abdomen to the back, assess him for absent bowel sounds and for abdominal rigidity and tenderness. If these occur, suspect a perforated ulcer or acute pancreatitis. Start an I.V. line for fluids and drugs, administer oxygen, and insert a nasogastric tube while withholding food.

History and physical examination
If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient’s expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescription and over-the-counter drugs.

Next, perform a thorough physical examination. Observe skin colour, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient’s posture if pain doesn’t prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness.

Then ask the patient to walk first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜” (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, place the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this manoeuvre with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.
Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

Medical causes

Abdominal aortic aneurysm (dissecting)
Life-threatening dissection of an abdominal aortic aneurysm may initially cause low back pain or dull abdominal pain, but it usually produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, though, it no longer pulsates. Aneurysm dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

Appendicitis
Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney’s point in the right lower quadrant. In retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney’s point), and rebound tenderness. Some patients also have painful urinary urgency.

Ankylosing spondylitis
Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn’t relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasionally iritis.

Cholecystitis
Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours; many patients have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right-upper-quadrant tenderness, abdominal rigidity, pallor, and sweating.

Chordoma
A slowly developing malignant tumour, chordoma causes persistent pain in the lower back, sacrum, and coccyx. As the tumour expands, pain may be accompanied by constipation and bowel or bladder incontinence.

Endometriosis
Endometriosis causes deep sacral pain and severe cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It’s accompanied by constipation, abdominal tenderness, dysmenorrhoea, and dyspareunia.

Intervertebral disk rupture
Intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It’s accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient’s spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.

Lumbosacral sprain
Lumbosacral sprain causes localized aching pain and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine and movement intensify the pain, whereas rest helps relieve it.

Metastatic tumours
Metastatic tumours commonly spread to the spine, causing low back pain in at least 25% of patients. Typically, the pain begins abruptly, is accompanied by cramping muscle pain (usually worse at night), and isn’t relieved by rest.

Myeloma
Back pain caused by myeloma—a primary malignant tumour— usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.

Pancreatitis (acute)
Pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move about restlessly.

Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, and tachycardia; some patients experience abdominal guarding and rigidity, rebound tenderness, and hypoactive bowel sounds. Jaundice may be a late sign. Occurring as inflammation subsides, Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

Perforated ulcer
In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This life-threatening disorder also causes boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absence of bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.

Prostate cancer
Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also cause hematuria and decreased urine stream.

Pyelonephritis (acute)
Pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.

Reiter’s syndrome
In some patients, sacroiliac pain is the first sign of Reiter’s syndrome. Pain is accompanied by the classic triad of conjunctivitis, urethritis, and arthritis.

Renal calculi
The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. It varies in intensity but may become excruciating if calculi travel down a ureter. Calculi in the renal pelvis and calyces may cause dull and constant flank pain. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover any expelled calculi for analysis.

Rift Valley fever
Rift Valley fever is a viral disease generally found in Africa, but recent outbreaks have occurred in Saudi Arabia and Yemen. It’s transmitted to humans from the bite of an infected mosquito or from exposure to infected animals. Rift Valley fever may present as several different clinical syndromes. Typical signs and symptoms include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and haemorrhage. Inflammation of the retina may result in some permanent vision loss.

Sacroiliac strain
Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or a gluteus medius or abductor lurch.

Smallpox (variola major)
Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites of the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the oral mucosa, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Spinal neoplasm (benign)
Spinal neoplasm typically causes severe localized back pain and scoliosis.

Spinal stenosis
Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.

Spondylolisthesis
A major structural disorder characterized by forward slippage of one vertebra onto another, spondylolisthesis may produce no symptoms or may cause low back pain with or without nerve root involvement. Associated symptoms of nerve root involvement include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar spine may reveal a “step-off” of the spinous process. Flexion of the spine may be limited.

Transverse process fracture
This type of fracture causes severe localized back pain with muscle spasm and hematoma.

Vertebral compression fracture
A vertebral compression fracture may be painless initially. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.

Vertebral osteomyelitis
Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.

Vertebral osteoporosis
Vertebral osteoporosis causes chronic aching back pain that is aggravated by activity and somewhat relieved by rest. Tenderness may also occur.

Other Causes

Neurologic tests
Lumbar puncture and myelography can produce transient back pain.

Special considerations
Monitor the patient closely if the back pain suggests a life-threatening cause. Be alert for increasing pain, altered neurovascular status in the legs, loss of bowel or bladder control, altered vital signs, sweating, and cyanosis.
Until a tentative diagnosis is made, withhold analgesics, which may mask symptoms. Also withhold food and fluids in case surgery is necessary. Make the patient as comfortable as possible by elevating the head of the bed and placing a pillow under his knees. Encourage relaxation techniques such as deep breathing. Prepare the patient for a rectal or pelvic examination. He may also require routine blood tests, urinalysis, computed tomography scan, appropriate biopsies, and X-rays of the chest, abdomen, and spine.

Fit the patient for a corset or lumbosacral support, but instruct him not to wear it in bed. He may also require heat or cold therapy, a backboard, a convoluted foam mattress, or pelvic traction. Explain these pain-relief measures to the patient. Teach the patient about alternatives to analgesic drug therapy, such as biofeedback and transcutaneous electrical nerve stimulation.

Be aware that back pain is notoriously associated with malingering. Refer the patient to other professionals, such as a physical therapist, an occupational therapist, or a psychologist, if indicated.

Paediatric pointers
Children may have difficulty describing back pain, so be alert for nonverbal clues, such as wincing or refusing to walk. Closely observe the family dynamics during history taking for clues of child abuse.
Back pain in children may stem from intervertebral disk inflammation (diskitis), neoplasms, idiopathic juvenile osteoporosis, and spondylolisthesis. Disk herniation typically doesn’t cause back pain. Scoliosis, a common disorder in adolescents, rarely causes back pain.

Geriatric pointers
Suspect metastatic cancer—especially of the prostate, colon, or breast—in older patients with a recent onset of back pain that usually isn’t relieved by rest and worsens at night.

Patient counselling
If the patient has chronic back pain, reinforce instructions about bed rest, analgesics, anti-inflammatories, and exercise. Also, suggest that they take daily warm baths to help relieve pain. Help the patient recognize the need to make necessary lifestyle changes, such as losing weight or correcting poor posture. Advise patients with acute back pain secondary to a musculoskeletal problem to continue their daily activities as tolerated, rather than staying on total bed rest.

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What is Acoustic Neuroma?

2009-10-04T16:24:23+02:00

An acoustic neuroma is a skull based nerve sheath tumour that constitutes about 6% of all primary intracranial tumours. They are usually benign and a slow growing tumour which arise primarily from the vestibular portion of the VIII cranial nerve and lie in the cerebellopontine angle - a wedge shaped area bounded by the petrous bone, the pons and the cerebellum.

Diagnosis
It is a scary moment when your doctor tells you that you have a "brain tumour" called acoustic neuroma (vestibular schwannoma). You think you are the only one with this disease and you will soon die or at least become a physical wreck. You fear the only treatments available are either ineffective or very dangerous.

Fortunately, this is all wrong. You are not alone: between 1000 and 1500 new acoustic neuroma patients are diagnosed in the United Kingdom alone every year. And effective, low-risk treatment is available.
Acoustic neuroma was described for the first time in Holland in 1777. A comprehensive clinical description was presented in 1830. Although the first successful removal of an acoustic neuroma was performed in 1894, the mortality following surgery at the turn of the century was at least 80%.

Excision of the tumour was the standard treatment and the only available option for many years. The results improved gradually but were still far from satisfactory in the early 1960s, when microsurgical techniques were gradually introduced into this field in the USA.

In 1951, the Swedish neurosurgeon Lars Leksell presented the idea of letting a large number of converging beams of ionizing radiation crossfire targets in the brain. He coined the term "radio surgery" to describe this concept, since the way radiation was used differed greatly from conventional radiotherapy. He suggested radio surgery for the treatment of deep-seated brain tumours.

The first device for routine clinical use based on this idea was the prototype Gamma Knife constructed in 1967-68. Dr. Leksell treated the first acoustic neuroma with the technique in June 1969 at Karolinska Hospital in Stockholm, Sweden. Since then, more than 10,000 acoustic neuroma patients have been treated with this technique worldwide.

The Gamma Knife
This is an 18-ton machine with 201 permanently mounted cobalt-60 sources arranged spherically around the patient's head. These sources emit gamma radiation, which is similar to diagnostic X-ray (not laser as sometimes assumed) but with higher energy. These beams are precisely shaped through two consecutive sets of tungsten channels (collimators). They all focus on one point. Here, the radiation is very powerful. However, each individual beam on its way through the skull is weak and will not cause any detectable biological effects. The gamma radiation destroys molecules in the tumour cells so they can no longer reproduce and eventually will die.

The Gamma Knife is precise down to half a millimetre or even less (about 1/50 of an inch). Thus, a high dose of radiation can be delivered to targets with little harm to important sensitive structures just millimetres away or even adjacent to the surface. Stereotactic radio surgery is performed by a team composed of neurosurgeons, radiation oncologists, medical physicists and a nursing staff. Specialists in neuroimaging join the team when required.

Who can be treated?
In general, all acoustic tumours with an intracranial diameter of up to approximately 3 cm (1 1/4") qualify for Gamma Knife radio surgery. Over the years, larger tumours occasionally have been treated successfully with this technique. However, there is a greater risk that these larger tumours, even before any treatment, interfere with the circulation of the cerebrospinal fluid (CSF), causing hydrocephalus (an excessive accumulation of CSF). In this case, a shunt may be required to divert the CSF. Temporary swelling of a large tumour, induced by the Gamma Knife treatment, may occasionally result in hydrocephalus not present earlier. Surgical removals of a large tumour will frequently, though not always, eliminate the need for a shunt.

Patients with large acoustic neuromas - especially older patients - may still prefer the combination of Gamma Knife radio surgery and a shunt operation, a considerably less demanding procedure than microsurgical removal.
In fact, there are few reasons why Gamma Knife radio surgery should not be considered first instead of microsurgery for the vast majority of acoustic neuroma patients, including young and otherwise healthy ones.

What happens to the tumour?
Very few acoustic tumours threaten the patient's general health initially. The rationale for treating the tumour is to avoid the risk that the tumour might cause serious health problems or even death down the road if left alone to grow. By treating the tumour when it is still small, the risk of complications from treatment is generally smaller. Even so, a microsurgical procedure usually poses a greater immediate risk to the patient's health in terms of morbidity than does the tumour itself.

Gamma Knife radio surgery is different. The short-term and long-term risks are very low. The goal of the treatment is to kill or inactivate the tumour cells so they no longer duplicate. Since acoustic neuroma is a very benign type of tumour, it need not be completely destroyed. Instead, the aim is to stop further growth. An acoustic tumour that does not grow will not jeopardize the patient's health in the future.

In a benign tumour such as acoustic neuroma, with a very slow cell turnover, it will take some time for the radiation to affect the cells in a way that can be detected clinically or by imaging. Therefore, radio surgery has a less immediate effect than microsurgery.

Shrinkage actually is found in the vast majority of tumours when they are followed long enough. One year after the Gamma Knife treatment, shrinkage is confirmed in about one-third of the tumours. After four years, two-thirds of the tumours are smaller, and by 10 years, more than 90% have shrunk.

Signs of lack of response to radio surgery, in general, appear within one to three years of treatment. At least in my experience, failure is extremely unlikely to occur when five years or more have elapsed.
This statement may not apply for acoustic neuromas associated with neurofibromatosis 2 (NF2) in which case recurrence may occur later following Gamma Knife treatment as well as microsurgery.

Specialist Surgeons have found that Gamma Knife treatment can be repeated without increased risks if the acoustic neuroma did not respond as expected (unchanged size/shrinkage) to the first treatment. Microsurgery can also be selected, depending on the patient's preference.

Acoustic neuromas sometimes increase in size temporarily as a reaction to the Gamma Knife treatment. This is actually a favourable sign indicating a brisk response. Such swelling usually is most obvious between 6 and 18 months after the procedure. It should not be confused with increase due to lack of response in which case the tumour size will not return to the baseline but continue to increase. A definite assessment should be made two years after the treatment: was the swelling merely temporary or did the tumour fail to respond to the treatment? In any case, resection should not be considered during this two-year wait.

Cranial nerve function
At experienced Gamma Knife centres, the incidence of temporary facial and trigeminal nerve dysfunction among acoustic neuroma patients is as low as less than 2-3%. Preservation of useful hearing currently is achieved in 55-75% in different series with the better results usually in smaller tumours. Hearing tends to remain stable when the first one to two years have elapsed after treatment.

The tinnitus (spontaneous noise) so frequently associated with the hearing loss in acoustic neuroma patients is usually not affected, for better or worse, by Gamma Knife treatment initially. Over time, some patients say they have experienced some improvement. It is hard to say whether this is a real reduction of the intensity of the noise or an adaptation to a steady noise level. Even though most acoustic neuromas arise from the balance nerve (and not from the adjacent hearing nerve), hearing loss in the affected ear is a much more frequent presenting symptom than balance disturbance. When asked about it, however, most acoustic tumour patients admit to some feeling of unsteadiness or episodes of dizziness. Sometimes these symptoms may increase temporarily after the Gamma Knife treatment, indicating a transient reaction in the balance nerve to the radio surgery.

Radio surgery or microsurgery?
Traditionally, tumour treatment is defined as successful when the tumour has been completely removed. This apparently does not apply for Gamma Knife radiosurgery for which other standards have to be accepted when the results are evaluated.

Stereotactic radio surgery has a number of evident advantages over microsurgery including no mortality, no risk of intracranial bleeding or infection, no post-surgical complications, short or no inpatient time, and almost no recovery period. In addition, Gamma Knife treatment almost eliminates the risk of permanent facial weakness and the need for further surgery to restore proper facial functioning including eyelid closing, excessive tearing or dry eye.

These features are in themselves usually so attractive to the patient that they may decide on radio surgery based on the very low risk of side effects. Of course, such a decision should focus primarily on the best way of eliminating the impact of the tumour and secondly on the risk of disturbances in adjacent structures, such as surrounding cranial nerves, induced by the treatment.

It has been reported that acoustic tumours that were first treated with radio surgery without response were difficult to remove with microsurgery because surrounding nerves and other structures were more adherent to the tumour's surface. The radio surgical treatment would stimulate the formation of scar tissue outside the tumour. The surgeons reporting these problems base them on the experience from a small number of tumours resected. The experiences reported are far from consistent. Because of lack of experience we do not conclusively know to what extent and how often this is a real problem. We should not be able to expand our experience very much since a second Gamma Knife treatment is almost always possible to perform in those few patients in whom the response to the first treatment was inadequate.

Another objection against radio surgery sometimes mentioned is that the treatment would induce the formation of new tumours or change the character of the treated tumour to become more aggressive. These are known risks with radiation in general. Based on known clinical data and theoretical considerations that risk is equal to or less than 1 per 1000 persons treated. This is an extremely low risk level, which in my mind is not a reason to withhold Gamma Knife radio surgery from young individuals who prefer radio surgery to microsurgery.

Comments

Spinal Fusion – Surgical Options

2009-10-01T13:56:53+02:00

Spinal fusion is a surgical procedure in which two or more vertebrae are joined or fused together. Fusion surgeries typically require the use of bone graft to facilitate fusion.
This involves taking small amounts of bone from the patient’s pelvic bone (autograft), or from a donor (allograft), and then packing it between the vertebrae in order to "fuse" them together. This can be accomplished either posteriorly or between the vertebral bodies. When it is done between vertebral bodies, bone graft, along with a biomechanical spacer implant, will take the place of the intervertebral disc, which is entirely removed in the process.
Spinal fusion surgery is a common treatment for such spinal disorders as spondylolisthesis, scoliosis, severe disc degeneration, or spinal fractures. Fusion surgery is usually considered only after extensive non-operative therapies have failed.

Three common fusion surgeries available at Specialist Surgical Units include posterior fusion and interbody fusion such as PLIF, ALIF, TLIF or XLIF.

PLIF
PLIF stands for Posterior Lumbar Interbody Fusion. In this fusion technique, the vertebrae are reached through an incision in the patient’s back (posterior). The PLIF procedure involves three basic steps:

Pre-operative planning and templating.
Before the surgery, the surgeon uses MRI and CAT scans to determine what size implant(s) the patient needs.

Preparing the disc space.
Depending on the number of levels to be fused, a 3-6 inch incision is made in the patient’s back and the spinal muscles are retracted (or separated) to allow access to the vertebral disc. The surgeon then carefully removes the lamina (laminectomy) to be able to see and access the nerve roots. The facet joints, which lie directly over the nerve roots, may be trimmed to allow more room for the nerve roots. The surgeon then removes the affected disc and surrounding tissue and prepares bone surfaces of adjacent vertebrae for fusion.

Implants inserted.
Once the disc space is prepared, bone graft, allograft, or BMP with a cage (a biomechanical spacer implant) is inserted into the disc space to promote fusion between the vertebrae. The implant (cage) may be made of bone, metal, carbon fiber or other material. Additional instrumentation (such as rods or screws) will also be used at this time to further stabilize the spine. Most surgeons do not recommend this procedure without using fixation because of high complications.

TLIF
TLIF stands for Transforaminal Lumbar Interbody Fusion. This fusion surgery is a refinement of the PLIF procedure and has recently gained popularity as another technique of surgical treatment for conditions affecting the lumbar spine. The TLIF technique involves approaching the spine in a similar manner as the PLIF approach but more from the side of the spinal canal through a midline incision in the patient’s back. This approach reduces the amount of surgical muscle dissection and minimizes the nerve manipulation required to access the vertebrae, discs and nerves. The TLIF approach is generally less traumatic to the spine, is safer for the nerves, and allows for minimal access and endoscopic techniques to be used for spinal fusion.

As with PLIF and ALIF, disc material is removed from the spine and replaced with bone graft (along with cages, screws, or rods if necessary) inserted into the disc space. The instrumentation helps facilitate fusion while adding strength and stability to the spine. Currently surgeons use many state of the art cage technologies including those made of bone, titanium, polymer, and even bioresorbable materials.

ALIF
ALIF stands for Anterior Lumbar Interbody Fusion. This procedure is similar to PLIF, however it is done from the front (anterior) of the body, usually through an incision in the lower abdominal area or on the side. This incision may involve cutting through, and later repairing, the muscles in the lower abdomen. At our practice, a mini open ALIF approach is available that preserves the muscles and allows access to the front of the spine through a very small incision. This approach maintains abdominal muscle strength and function and is oftentimes used to fuse the L5-S1 disc space.

Once the incision is made and the vertebrae are accessed, and after the abdominal muscles and blood vessels have been retracted, the disc material is removed. The surgeon then inserts bone graft (and anterior interbody cages, rods, or screws if necessary) to stabilized the spine and facilitate fusion.

XLIF
XLIF stands for eXtreme Lateral Interbody Fusion. This is a relatively new minimally invasive approach to the anterior spine that avoids an incision that traverses the abdomen and also avoids cutting or disrupting the muscles of the back. In this fusion technique, the disk space is accessed from a very small incision on the patient’s side (flank) a couple of inches in length, occasionally with another small incision (one inch long) just behind the first incision. Special retractors are utilized, in addition to a fluoroscopy machine, which provides real-time x-ray images of the spine. In addition, special monitoring equipment is used to determine the proximity of the working instruments to the nerves of the spine. The disk material is removed from the spine and replaced with a bone graft, along with structural support from a cage made of bone, titanium, carbon-fiber, or a polymer. This technique typically allows a shorter hospital stay and may be less painful than traditional approaches to the spine, however it also has limitations. Only those vertebra of the spine that have clear access from the side of the body can be approached using this technique. Also, only one or two levels can usually be accessed via this method.

Minimal Access
Spinal Surgeons routinely do several types of spinal procedures utilizing minimal access techniques. The development of these techniques originated with the application of endoscopy during microdiscectomy surgery for herniated lumbar discs. It has now been applied to fusion surgeries. Ask your consultant if this could be appropriate for you.

After Fusion Surgery
Recovery time is different for every patient. However, most patients are up and walking by the end of the first day after surgery. Most patients can expect to stay in the hospital for 3-5 days depending on their condition. Once released from the hospital, patients who have undergone surgery are given a prescription for pain medications to be taken if needed, as well as a detailed post-operative activity, physical therapy/exercise plan to help ease recovery and return to a healthy life.

Comments

Degenerative Joint Disease

2009-10-01T10:56:11+02:00

Questions To Ask Your GP about Degenerative Joint Disease

Are there clinical signs of degenerative joint disease (based upon history and examination)?

If I am a younger patient, should I be evaluated for another cause, other than OA, that may be surgically correctable?

Are x-rays indicated?

Are other tests, such as blood work and MRI indicated?

Would exercise or activity change help?

Is there a role for bracing, orthotics, or other splints?

What medications do you recommend – analgesics, anti-inflammatories, glucosamine?

Should I consider an injection, and, if so, what type: steroid versus hyaluronic acid?

What are the side-effects of any of these medications or injections?

Will surgery be required, and is there a non-joint replacement option/alternative?

What can be done to retard the degenerative process?

A Guide to the Treatment of Degenerative Joint Disease

Treatment of OA depends upon multiple factors including patient age, activities, medical condition, and x-ray findings. Patients with mild to moderate osteoarthritis of weight-bearing joints (hips and knees) may benefit from a supervised exercise program such as walking. Non-impact activities such as swimming, cycling, and walking tend to be more comfortable for patients with OA. In a younger patient with signs or symptoms of OA, other causes of arthritis such as deformity, medical conditions, or bone disorders should be carefully sought for in order to rule out other conditions.

A program of regular physical activity can strengthen the muscles, tendons, and ligaments surrounding the affected joints and preserve mobility in joints that are developing bone spurs. Many physicians believe that osteoarthritis may be prevented by good health habits. Remaining active, maintaining an ideal body weight, and exercising the muscles and joints regularly so as to nourish cartilage.

A first line of simple treatment - acetaminophen (Tylenol) is as effective and has less side effects than other non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen, or aspirin.
Glucosamine-chondroitin sulfate may be prescribed by your doctor. This medication, when taken over a period of months, may reduce pain and symptoms by restoring or replenishing nutrition to diseased cartilage cells. It tends to be more effective in earlier stages of OA.

The dosage and combination of each ingredient is an important aspect of the therapy, as not all preparations and brands are the same. Patients who fail to improve on acetaminophen or glucosamine may be treated with salicylates and other oral anti-inflammatories ( NSAIDs).
Previously, medications such as Vioxx, Celebrex, and Bextra (Cox-2 NSAIDS) were preferred due to less gastrointestinal side effects (ulcers) and improved pain relief for arthritis.

However, currently the use of these medications should be reviewed with your doctor, as concerns about their use in certain patients has been recently reported. More traditional NSAIDS (ibuprofen, naproxen, etc.) are available over the counter, and they also provide excellent relief of symptoms. Capsaicin cream 0.25% applied twice daily may reduce knee pain. Intra-articular (within the joint) injections of steroids may also be helpful, although the duration and amount of pain relief is often unpredictable, especially in more advanced stages of OA.

Alternative injections of hyaluronic acid peparations (sodium hyaluronate) are also available and may be very useful in the treatment of OA. These injections are indicated for OA of the knee, and typically require an injection once a week, over a period of three to five weeks (i.e., three to five injections). The hyaluronic acid is injected into the knee joint, and similar to oral glucosamine, may provide nutrition to the diseased cartilage cells and collagen within the cartilage. The fluid is a gel-like material that appears to act initially like a lubricant for the joint. However, studies have shown that the lubricant aspect plays little role and, in fact, the fluid is absorbed quickly by the cartilage cells.

Bracing, splinting, and other orthotic treatments may be useful in managing or “unloading” an arthritic joint surface. These nonoperative treatments are simple, often effective, however cost and ease of use are factors in their selection in treatment.

Surgery may be dramatically effective for patients with severe osteoarthritis of the weight-bearing joints. Total hip replacement and newer hip resurfacing replacements and total knee replacement or unicompartmental (partial) knee replacement can be extremely effective. Joint replacement is now being performed in younger patients also. The concerns about wear of the prosthetic joint surface in younger patients make this the most challenging aspect of future research in this area. Newer joint surfaces for joint replacement including highly cross-linked polyethylene, metal on metal bearing, ceramic bearings, and others have emerged and currently are available in the U.K.

Although arthroscopic surgery for knee osteoarthritis is a common procedure, its long-term effectiveness is unclear, and may be best for symptoms such as catching, locking, or those that have been present for only a short duration. In addition, not all patients that have arthritis should have an arthroscopy, as this may not improve their symptoms.
In younger patients, hip and knee preserving procedures should be considered, in order to avoid a hip or knee replacement. Although performed less frequently, hip and knee preserving procedures, such as osteotomy (cutting the bone and realigning the bone or joint surface), may restore a joint to a normal alignment and be an excellent alternative to joint replacement.

Comments

Herniated Disc Question

2009-09-30T12:42:49+02:00

Question:

Hi, I'm a 30 year old male with some back trouble. I have herniated discs at L4-L5, and L5-S1. From the latest MRI 2 months ago the higher one is worse (L4-L5) about a 12mm buldge. I don't know anymore, it's been 3 years. I'm careful, exercise watch how I move etc. Pain is always there. I've recently had cortisone injections which did not do me much good. The pain management doctor guy couldn't believe that I've never tried the shots before, and said I must have a very high threshold for pain. I mean I get the sciatic pain and stuff, it pretty bad. I've been trying to live with it and it's becoming extremely difficult. I'm beginning to have a lot of anxiety over things now, and I know it's the root of it. Probably because the injections proved useless.

So what do I do now? Surgery is my only option I suppose. I pray to God for relief every single day, just to live a normal lifestyle again and be able to tell people I had a good day and mean it. I have a career as a union electrician, I worry about not being about to do that. I'm sick and tired of living life just wanting to get through a day and not worry about what a can accomplish. Is surgery my next step??

Answer:

The usual procedure is to try all conservative measures first, and if they do not relieve your pain, then surgery can be an option.

The longer you allow the nerves to be compressed the more likely you will develop permanent nerve damage, which is something you don't want to happen.

Have you been diagnosed by a spine surgeon?

Have you had surgical options given to you?

Decompression Therapy maybe an option to consider, however there is really no documented scientific evidence that "decompression therapy" actually works, and there have been cases that it can make conditions worse.

I do know a couple of people that have given it a try though. They found it very expensive, insurance doesn't usually pay for it, and if pain relief was achieved, it was very temporary, lasting a day or two and then another session was required to relieve the pain.

In the end, all 3 people needed surgery to relieve the pain.

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What is the Feldenkrais Method?

2009-09-29T13:21:18+02:00

The Feldenkrais Method is a form of body awareness that is often thought of as alternative or complementary medicine. As designed by Dr Moshé Feldenkrais, in the 1960s, the goal of the Feldenkrais Method was to take a holistic approach to movement. Awareness of the movement of the body could promote subtle changes, enhance movement ability, and perhaps aid in treating those with injuries that inhibit movement.

Moving in a holistic way is called positive functioning. To Dr. Feldenkrais, positive functioning was key to being healthy. Positive functioning not only deals with the way we move, but the way we think about moving. Thus the Feldenkrais Method can be said to be a mind/body experience.

The Feldenkrais Method became popular in the US in the early 1970s. Dr. Feldenkrais taught at Esalen, and then offered seminars in San Francisco in the late 1970s, and in Massachusetts in the early 1980s. Essentially, two types of Feldenkrais method are practiced.

The first type of Feldenkrais Method can be taught in classes of numerous people, with a single instructor. These classes, called Awareness Through Movement (ATM), have students perform very simple exercises per the instructor’s directions. Unlike a calisthenics class, movements may be quite small and can generally be performed by people of all fitness levels. The goal is to connect mind and body by being aware of how the body moves.

The second type of Feldenkrais Method is called “functional integration.” This may be a private lesson where the instructor moves the student’s body. Functional integration is often used to help people overcome specific movement problems, which perhaps might result from an old injury. The movements are again quite subtle, but are meant to teach the person how to move with greater ease. ATM may also be taught privately, but is more often taught to a small group of students.

Currently, practitioners of the Feldenkrais Method must have 800 hours of training before being certified in their profession. In the US, those trained in the method usually have certification with the Feldenkrais Guild of North America. Other countries also have certifying agencies, and it is important to work with someone who is actually registered with a guild.

Some with injuries or conditions like arthritis find the Feldenkrais Method to be of tremendous assistance. Others do not benefit much from the method. It does require a skilled practitioner, an open mind, and an extraordinary amount of self-awareness for some to find success.

Popularity of the Feldenkrais Method was highest in the early 1980s. Since then, other mind/body methods, especially some forms of yoga, have surpassed the Feldenkrais Method. Yoga and Feldenkrais can actually be quite compatible, and many find benefits from a combination of both practices.

Comments

Sex and Back Pain

2009-09-27T18:39:13+02:00

Sex and Back Pain don’t go together very well do they?

And if you or your partner are among the 35 million people who have back pain, you know that back pain can disrupt your relationship.

Sex is an important part of the intimacy between couples, and attitudes about sex, about rejection and about our self-image when we don’t feel up to a sexual encounter can haunt a couple for a long time.

Sex is supposed to be pleasurable for both of you and the fear of
hurting yourself or your partner inhibits the spontaneous joy that
you probably felt before your back pain developed. But what can you
do about it? Most couples in which one or the other is restricted
by back pain will eventually get around to realising that back pain
does not automatically mean no more sex. What it does mean is that
you will need to make some accommodations to the pain and or the
fear of it. It also means you will need to talk about sex in a
slightly different way than you are used to.

Let’s back up for a second and begin with a very strong suggestion.
Because pain has both a psychological component and a physical
component, getting a sound diagnosis is critical to putting your
mind at rest about what is wrong and secondly having a sound
diagnosis will also give you guidelines for your physical
limitations.

Secondly, after you have the diagnosis, involve the doctor or
physical therapist in a frank discussion about do’s and don’ts.
Maybe that’s an uncomfortable subject for you, but these days we
are talking more openly about sex and you should tap into the
doctor’s experience here. In a perfect world the doctor would open
the discussion for you, but if they don’t you may have to initiate
it. Ideally your partner should be present because he or she will
have his or her own questions and concerns.

Sex Advice

Starting off right
To start sex off right, start off with a massage, or ice down the
painful area. A warm shower together might help too. That way the
muscles are relaxed.

Positions
Here are some sexual positions that can help you enjoy a pain-free
experience.

For males:

1. Lay on a firm surface and use pillows to support your knees and
head. You might like to try placing a small rolled towel under your
lower back.
2. Try a side-by-side position.
4. Place a pillow under your lower back while your partner straddles
you on top. You can also sit in a sturdy chair instead of lying down.

For females:

1. Try missionary position with the legs bent toward the chest.
2. Sit on the edge of a chair and have your kneel between your legs
for entry.
3. Rear entry may also be more comfortable for women with back pain.
Try it kneeling on the bed or lying on your belly with a pillow under
her chest.
4. Sit on your partner's lap as he sits in a chair.

Remember, the health of your back is dependent on many dynamic factors.
Your symptoms may change over time so you may need to work with your
health care provider from time to time as you go through the many
stages of recovery. A word of caution is in order at this point. It
is pretty common to begin feeling better and then over do it and have
your back pain symptoms flair up. I call this, the Eureka effect
and it can happen to anyone. Just remember that as you improve
gradually, so should your activity level also increase gradually.

As I mentioned earlier pain has two parts. There is the physical part.
This is the actual stimulation of the nerve, like a painful tooth or a
herniated disc pressing on the nerve. And then there is the subjective
or the psychological part. This is how it feels to you and includes,
among other things, such attitudes as fear that it will get worse or
last forever, what will it means to be chronically disabled, and what
you believe your partner thinks about it as well as how you are coping
with your condition.

So, at the top of your agenda there needs to be a frank discussion of
your pain limitations and expectations about sex. It is a mistake to
believe that your partner understands what it feels like. It is your
responsibility to communicate those limitations as clearly as possible;
it is their responsibility to listen and try to understand. Pain, after
all, is invisible and subjective. That means your pain is unique to you.
We have heard people liken back pain to everything from a hot poker
going down one or both legs to a chronic aching sensation localized to
the lumbar area. It doesn’t matter what words you use, just try to
explain the pain, what causes it (position, certain movements, or
whatever), and what feels good or is what is comfortable for you.

Is it obvious that if it hurts, don’t do it is generally good advice but
some positions and techniques hurt more than others? It may require some
gentle experimentation to find out what works but as in most sex advice,
“gentle” is the best place to start.

In terms of maximizing yours and your partner’s sexual pleasure, it is
very important to stress that all you really need is your imagination and
the willingness to experiment to open up new areas of intimacy. But it
all begins with willingness to try. And given that, you just may find
that the challenge of your back pain can be turned into the juice of new
sources of mutual pleasure.

Comments

Scoliosis in Women

2009-09-25T17:37:03+02:00

Scoliosis means that your spine, or "backbone," is curved.

What Causes Scoliosis?
There are different types of scoliosis and different reasons that might cause your spine to curve. The most common type of scoliosis is called idiopathic scoliosis and has no known cause. The back just doesn't grow as straight as it should, and no one knows why. There are also other less common causes of scoliosis. Sometimes, the spine appears to be curved because of a difference in leg length. And rarely, some babies are born with spinal defects that cause the spine to grow unevenly. This last type of scoliosis is called congenital scoliosis.

Who gets scoliosis?
Anyone can get scoliosis. But the most common type of scoliosis, idiopathic scoliosis, usually occurs after age 10. Girls are more likely to develop idiopathic scoliosis then boys are. Check out the list of some famous people with scoliosis!

•Sarah Michelle Gellar - Actress/Model
•Janet Evans - Olympic Swimmer
•Alexandra Marinescu - Olympic Gymnast
•Renee Russo - Actress/Model
•Malanie Blatt - All Saints Star
•Liza Minelli - Singer/Broadway actress
•Isabella Rossellini - Actress/Model
•Chloe Sevigny - Actress
•Daryl Hannah - Actress

Everyone between ages 10-11 should be checked for scoliosis by their health care provider. It is especially important to be checked regularly if you have a parent, sister, or brother with scoliosis, since scoliosis can run in families.

How is scoliosis diagnosed?
An examination to check for scoliosis usually includes a physical examination, and sometimes may include an X-ray evaluation and curve measurement.

•Physical Examination
Your health care provider will look at your back, chest, hips, legs, feet, and skin. He or she will check to see if your shoulders are even, whether your head is centered over your shoulders, and whether opposite sides of your body look even. He or she will also examine your back muscles, while you are bending forward, to see if one side of your rib cage is higher than the other. If there is a significant asymmetry (a big difference between opposite sides of your body), your health care provider may suggest an x-ray or a referral to an orthopedic spine specialist (a doctor who has experience treating people with scoliosis).

•X-ray evaluation
If you have a medium or large spinal curve, unusual back pain, or you still have a lot of growing to do, your health care provider will arrange for you to have an X-ray. You will be asked to stand facing the X-ray machine. An X-ray is a detailed picture of your spine. Your health care provider will be able to see any curves in your spine and can figure out if they need to be watched or treated.

•Curve measurement
The doctor measures the curve on the X-ray image. He or she finds your vertebrae at the beginning and end of the curve and measures the angle of the curve. Curves that are greater than 20 degrees may need treatment.

What kinds of treatment are available?
Depending on the location, degree (severity) of the curves, and growth remaining, your health care provider will recommend observation, bracing, or surgery.

•Observation
Some curves get worse with growth. Others don't change and some may even get better. Some curves require no treatment. However, your health care provider will want to watch your curve carefully to make sure that it does not get worse as you grow.

•Bracing
If your curve is large enough and you are growing, your doctor may recommend a brace. The scoliosis brace is designed for you and your particular curve. It holds your spine in a straighter position, and it helps prevent your curve from getting worse while you are growing. A brace will not make your spine straight, but it can help improve the curve or prevent it from getting worse.

•Your doctor will give you specific directions about how to put on your brace, when to wear it, and how long to wear it. The brace needs to be worn for the full number of hours prescribed by your doctor until you finish growing. Generally, braces can be removed for activities such as showering, swimming, and sports. The braces are made of firm plastic and fit closely over the hips. Almost all braces can be hidden beneath clothing, and you can continue to do all athletic activities.

•Surgery
Bracing does not work for everyone and every curve. If you have a very large curve or one that does not stop getting worse with a brace, your doctor will probably recommend surgery. There are different types of surgery. Some may be better for your specific curve than other types. The main purpose of scoliosis surgery is to fuse (join together) the bones of your curve. The fusion keeps your spine straight. Your surgeon will talk to you about your options, the different types of surgery, and the different types of implants available. Implants are devices that are inserted during surgery. They remain in your back after surgery and help keep your spine straight.

If you are considering surgery you should be sure to ask your surgeon the following questions:

•What will happen if I don't have surgery?
•What type of surgery will work best for me?
•What implants will be used?
•How straight will my spine be after surgery?
•How long will the operation take?
•What are the risks of this surgery?
•What are the benefits to getting this type of surgery?
•What is the scar like?
•How long will I have to remain in the hospital after the surgery?
•How long will it take to recover?
•When can I start being as active as I was before surgery?
•What permanent restrictions are there on activity?
•Can I talk to another patient/family who had the surgery?

What will happen if I ignore my scoliosis?
After you have been diagnosed with scoliosis, you may not think that treatment is that important. However, it is very important to treat scoliosis since spinal curves can become worse and cause physical changes to your spine. In the worst cases, scoliosis can cause changes in your chest and lungs and difficulty breathing. It is also important to treat curves since treatment is much more successful before curves become severe.

How do I cope with scoliosis?
If you are diagnosed with scoliosis, it doesn't mean you can't live a healthy and active life. Most teenagers with scoliosis are able to exercise, take part in sports and athletics, drive, and be involved in friendships and relationships.Teenagers with scoliosis can do pretty much everything that teenagers without scoliosis can do! It is also important to remember that if you are diagnosed with scoliosis, it is not your fault. Nothing you did caused the scoliosis, and there is nothing you could have done to prevent it. If you have scoliosis, the important thing is for you and your health care provider to choose and follow the best treatment plan for you.

Comments

Stabilising the Spine and the Dynesys System

2009-08-21T19:24:09+02:00

If your Spine Specialist discovers that a combination of physical therapy and medication does not solve your back problem, then they will order further diagnostic tests to help find the root cause of the pain and determine the severity of the problem. You should fill out a questionnaire about your symptoms, pain and mobility, and the specialist will complete a series of tests, including dynamic radiography for imaging and/or an MRI (Magnetic Resonance Imaging).

Taking into consideration your history, condition and situation, your specialist will use the test results to determine an appropriate treatment for you.

Non Surgical Treatment

Non-surgical or conservative treatment consists of a combination of rest, weight control, exercise, physical therapy, application of heat and cold, injections and/or anti-inflammatory medications. The persistence of pain is evaluated after this treatment. A spine specialist will decide whether surgical treatment is necessary.

Surgical Treatment

Your doctor may recommend surgical treatment under anaesthesia to realign the spine, restore the space between vertebrae and relieve pressure on the nerves that are causing pain. An anaesthesia test will be completed before surgery to evaluate possible risks. Your history, condition, diagnosis and the goals of the surgery are all considered when determining the best surgical procedure for you. Depending on the level of disc degeneration, the surgeon will choose between rigid fixation (which fuses vertebrae) and non-rigid fixation (also called dynamic stabilisation).

Spinal fusion, in which the affected discs are removed and the associated vertebrae gradually fuse together through new bone growth, has historically been the standard treatment and is still in use depending on the patient’s conditions. An implant of screws and inflexible rods holds the vertebrae in place during the fusion process.
A non-rigid, dynamic implant system is an alternative to fusion. Flexible materials between screws help to preserve anatomical structures, restore the healthy alignment of the vertebrae and relieve the weight overload on the vertebrae adjacent to the implant.

Spinal Fusion Surgery

Depending on the condition of the spine, the doctor may use an anterior approach, which means the incision will be in the abdomen, or a posterior approach, which means the incision, will be in the back.

Sometimes the doctor may choose to use a combination of the two. If the doctor uses a posterior approach, then a pedicle screw system is used to stabilise the spine while it fuses. The pedicle screw system may be used alone or it can be combined with another stabilising device.

During surgery, the doctor may relieve the nerve compression by removing the disc (the procedure is called a discectomy). The doctor may also relieve pressure on the nerve by trimming or removing the roof, or lamina, of the vertebra to create more space for the nerve (called laminectomy ). The doctor then restores the space around the nerves and prepares to stabilise the spine with the pedicle screw system. There are a number of components in a pedicle screw system, and the doctor will choose the ones that will work best for your spine.

The screws are placed through each side of the vertebrae in the part of the part of the bone called the pedicle. Rods are then attached to connect the screws and hold the spine in its restored position. The pedicle screw system is now secure. In the last step of the surgery, the doctor places bone graft (small chips of bone) alongside of the vertebrae to be fused or puts the graft in and around a device that's placed between the vertebrae. Bone graft can come from the patient's hipbone, from a bone bank, or from a combination of both.

The pedicle screw system will hold the spine stable until the bone graft fuses with the vertebrae. Although bone fusion is a natural biological process, complete fusion can take up to one year. In some cases, people may have trouble fusing their spine. Many things, such as smoking or various medications can interfere with successful fusion. Your doctor will discuss with you the risks associated with your specific surgery.

Spinal Non Fusion Surgery with the Dynesys Dynamic Stabilisation System

This non-rigid, dynamic implant system is an alternative to fusion. Flexible materials between screws help to preserve anatomical structures, restore the healthy alignment of the vertebrae and relieve the weight overload on the vertebrae adjacent to the implant.

How can the Dynesys System help?

The Dynesys System is a pedicle-screw fixation system, an implant device consisting of a spacer, cord and pedicle screw. It offers a unique approach to stabilisation and mobilisation of the spine and pain relief -- a "dynamic" approach -- that relies on flexible materials and preserves much of the spinal anatomy.

Which patients are candidates for the Dynesys System?

The Dynesys System can be used in skeletally mature patients to provide immobilisation and stabilisation of spinal segments. It is used to treat degenerative disc disease in the lumbar and / or sacral regions when there is evidence of resulting neurologic impairment.

Your doctor will decide the best way to perform surgery for your unique conditions. Keep in mind that other factors will also have an impact on your recovery after surgery. Obesity, smoking and psychological problems may decrease your chance for a successful outcome.

When should the Dynesys System not be used?

The Dynesys System should not be used in the cervical spine or for patients that are obese, pregnant, abuse alcohol or other drugs, or who have:
 an active or systemic infection
 mental illness
 severe osteoporosis or osteopenia
 sensitivities or allergies to metals, polymers, polyethylene, polycarbonate urethane and polyethylene terephthalate
 soft tissue deficit
 congenital abnormalities
 tumours
 inadequate pedicles of the thoracic, lumbar and sacral vertebrae

The Dynesys System is also not appropriate for individuals with any medical or mental condition that puts them at high risk from surgery of this severity, those with a condition that will not allow them to benefit from the surgery or decrease the useful life of the device, and those who are unwilling or unable to follow post-operative instructions.

What does surgery with the Dynesys System involve?

The Dynesys System is compatible with conventional posterior surgical techniques, and in some cases can be implanted using a minimally invasive approach. On average, the procedure to implant the Dynesys System takes two to three hours which is similar to the time required for traditional fusion procedures, depending on patient conditions.

The Dynesys System is attached to the bony extrusion (pedicle) on each side of the affected segment. Once in place, the components create a dynamic push-pull relationship that stabilises the affected joints and keeps your vertebrae in a natural position.

What to Expect Before and After Surgery

Before Surgery

You are an active participant in the surgery’s success. Proper preparation for surgery is mandatory. It is important to be as fit as possible when you go into the clinic; this will help your recovery and enable you to be mobile and active more quickly after surgery.
Improve your general health and follow healthy dietary recommendations. Both obesity and smoking increase the risks during the surgery and may complicate recovery.
Strengthen your muscles; some exercises may prepare your back muscles for surgery. Therefore your doctor may recommend exercises for you.
Inform you doctor of allergies, medicines and antibiotics. Patients who regularly take aspirin must, if recommended by his/ her doctor, stop taking them eight to ten days before surgery.

Surgery

A spinal implantation follows a very accurate protocol and is a standard operation for spine surgeons. The medical team is familiar with the procedure and is fully equipped to take care of you.
The surgery takes place under general anaesthetic. The possible risks with anaesthesia will be discussed with you before surgery.

Depending on the most suitable surgical posterior approach, either one or two skin incisions will be made on your lower back.

The standard duration of surgery is two hours (1), typically with minimal blood loss. Post-surgical pain is usually controlled by a sedative injection in the spinal canal during surgery.
(1) Depending on the number of levels operated on.

Risks

Any surgery involves risk. Your doctor will inform you about the risks related to the surgery and your case.

After Surgery

A trained medical team will accompany you in the recovery room. Depending on your condition, you will likely be asked to move around the day after surgery. Early movement is important to beginning an efficient recovery process after a surgery with a dynamic spinal implant. With each new step forward, you improve your future ability to move and improve your quality of life.

The day after surgery, measures will be taken to relax muscles; you should be able to make controlled movements. Extensive movements that tax the back are not recommended early on. You back should not be required to withstand too high a load at this point, and you should take care not to start driving too early.

Any surgery involves risk. Contact your doctor if you have any of the following symptoms after surgery:
 Signs of infection, such as fever, chills, and redness around the incision or a feeling of pressure in the spine.
 Sudden pain or a significant increase in pain
 Loss of feeling in your hands or feet

After the surgery- Spinal Fusion

Recovery from spinal fusion surgery happens in stages as your body heals. The first stage of recovery involves the healing of the incision and soft tissues. This will happen over the first few weeks. Movement, such as walking, does a lot to help with healing. You can expect to be doing some walking as soon as the day after surgery, and you will be expected to walk every day after that. Your doctor may also have you go to physical or occupational therapy for gentle exercise in the early weeks of recovery.

Your doctor will monitor and evaluate the bone fusion throughout your recovery. This will mean visits to the doctor's office, where x-rays will be taken to see how the bone is fusing. Your doctor will tell you what things you can do to help your recovery.

Complete fusion surgery takes months, and recovery is different, for each patient. Depending on how many levels of your spine are fused, you may notice some changes in the flexibility of your back. Your doctor will tell you what you can expect during your recovery.

Spinal fusion surgery using a pedicle screw system is designed to stabilise your spine, giving you the ability to move more easily and with less pain. For most people, spinal fusion surgery offers significant relief and improved ability to move and function in their daily lives.

This information is meant to help you understand spinal fusion surgery and pedicle screw systems like the Silhouette ™, OPTIMA ZS or ST360 Systems, so you can work with your doctor to make the treatment decision that is right for you. If you have any questions, please talk to your doctor.

After Surgery - Dynesys Dynamic Stabilisation

It may take several weeks to fully recover from pain resulting from the surgery. However, you may feel almost immediate relief of any leg pain. Back pain should diminish over time now that the vertebrae have been stabilised and nerves are no longer compressed. In most cases, a short hospital stay is required to ensure you adjust to oral pain medication and can move without any problems. Most patients return home within a few days.

Following your surgery, your doctor will prescribe rehabilitation and follow-up visits as needed. It's important to follow your physician's instructions carefully to help ensure a full and quick recovery.
You need to modify your normal lifestyle to adjust to your spinal implant. You will gain more stability as your back muscles heal. Though you may be able to continue living life as normal, some measures need to be taken to preserve your back.

At Home

You need to modify your normal lifestyle to adjust to your spinal implant. Further regular exercises will be recommended to care for your back. These will strengthen muscles and your entire back. Though you may be able to continue living life as normal, some measures need to be taken to preserve your back.
To keep from overloading the implant:
 Do not carry heavy-weight objects
 Do not make large motions (2).
You may engage in some sports again, but only in a progression after few weeks, depending on your situation, the success of your therapy and the state of your muscles. Ask your doctor first. Your doctor can give you more information on what is right for you.
(2) Your doctor will give substantial details according to your case.

Symptoms to Watch for After Surgery

As your doctor will explain, any surgery involves risk. After surgery, if you have any of these symptoms, you should contact your doctor:
 Signs of infection (fever, chills, redness around the incision, increased pain, a feeling of pressure in the spine)
 Bleeding or excessive drainage from the incision
 Sudden pain, or a significant increase in your pain level
 Loss of feeling in your hands or feet
 Increased or ongoing shortness of breath

Are complications possible?

Surgery always involves some risk. General surgical complications may include:
 reactions to anaesthesia
 heart attack
 infection
 blood vessel damage/bleeding
 bruise (hematoma)
 pneumonia
 blood clots
 wound closure problems
 death

Potential risks associated with the implantation of the Dynesys System are similar to those associated with any spinal fusion procedure and those risks specific to the implantation of other pedicle-screw systems. They may include:
 tear in the outer lining of the spinal cord which may result in spinal fluid leakage
 temporary decreased or absent intestinal function
 leg pain
 nerve complications
 fractured sacrum
Please consult with your doctor for a complete list of all warnings and precautions.

What to Expect from the Surgery

The primary goal of this surgery is to restore segmental stability in order to relieve your back and leg pain. As with any treatment for pain, relief symptoms will vary from patient to patient.

How can I improve my chances of a good outcome?

It's well known that smoker’s experience lower surgery success rates than non-smokers. If you smoke, please consider stopping as far in advance of surgery as possible. In addition, poor nutrition impacts your body's ability to heal itself. Eat well-balanced, nutritional meals as far in advance of surgery as possible.

Comments

Sacroiliac Joint Syndrome

2009-07-15T13:22:19+02:00

Sacroiliac joint syndrome also known as sacroiliac syndrome and sacroiliac joint sprain, is a common cause of back pain and is regularly treated in Physical Therapist Clinics.

Even though the injury causes inflammation of the sacroiliac joint, it is not the same as sacroiliitis.
The sacroiliac (SI) joints are located on either side of the spine just below waist height. Looking from behind onto somebody's back you can see two dimples on either side just below the waist. That is where the SI joints are located.

The joints are between the two pelvic (iliac) bones, which join on to the sacrum, forming the two sacroiliac or SI joints.
Inside the joints is a system of ridges and grooves. The sacral side has a concave groove and the iliac side has a convex groove, which limit the movement. The joints also have a complex system of ligaments, which further strengthen the joints.

The main function of the sacroiliac joints is to transmit forces between the upper body and the lower limbs. They are designed to withstand large stresses.
Women tend to be affected more often than men since they tend to have more flexibility of their ligaments. The SI joints tend to lose their flexibility and we are less likely to sprain our SI joints as we get older.

Until recently the main anatomical textbook in medicine did not recognise that these joints moved. The Grey's Anatomy, since some years now, state that the sacroiliac joints do move, which has been a great help in making medical doctors accept that sacroiliac joints can benefit from chiropractic treatment.

How do the Sacroiliac joints get injured?

Sprains of the sacroiliac joints are caused by excessive movement; this can occur in a one off event such as a fall or car accident or more commonly developed over time due to repetitive micro-trauma.
Excessive stress on the joint capsule causes microscopic damage to the ligaments surrounding the joint. The joint then becomes inflamed and painful.

The body reacts to this by instructing the muscles to tighten up to prevent more damage but this muscle spasm tends to last for longer than it is useful, resulting in more pain.
It is common to get referred pain from the muscles that go into spasm. The most commonly involved are the piriformis, gluteal (buttock) and psoas muscles.

Causes of SI Sprain•

Repetitive micro-trauma: it means many small repetitive injuries, until the proverbial 'last straw'. That is why people often hurt themselves doing very trivial things such as bending to pick up a pen, and they hurt themselves before they even get to lift the pen. This can happen through fairly trivial activities. Maybe things that you have done a hundred times before.

•Muscular imbalance or weakness in the muscles surrounding the sacroiliac joints: these problems develop over a long period of time giving little or no symptoms until it is too late.
•Trauma such as a fall or road traffic accidents
•Prolonged bending or lifting
•Pregnancy: Hormones released in the last trimester to increase the laxity of the pelvic ligaments can make them more vulnerable to injury.

•Problems with the hip, knee and feet: can all put increased pressure on the sacroiliac joint, which can become painful over time due to repetitive strain.

Signs and Symptoms of SI Joint Sprain

•Pain on one or both sides over the joints and into the buttocks.
•Pain can also be felt into the back of the leg, the front of the thigh and groin.
•Pain is often after lifting or twisting; or can develop over a period of time.
•Pain is worse sitting and bending forward.
•Increased weight bearing such as standing on one leg increase the pain.
•Lying down eases pain.
•In most cases, there is no loss of strength, pins and needles or numbness.

An Osteopath, Chiropractor or other suitably qualified Physical Therapist is usually able to make a diagnosis based on the history and the signs and symptoms of the condition.

Sometimes, especially if the problem is long standing, if you have reached a certain age or if there is anything in your medical history to indicate it we may take an x-ray of the pelvis.
You cannot diagnose a sacroiliac joint sprain on an x-ray, CT or MRI scans alone. The diagnosis is made on the clinical findings - but the x-ray may help to rule out other causes and in some cases help the physical therapist determine which type of treatment is most appropriate. It can help to rule out underlying inflammatory conditions, sacroiliitis, such as Ankylosing spondylitis.

Treatment of a Sacroiliac Sprain

The healing time for a damaged ligament is between 4-6 weeks. Physical Therapy will normally help you get comfortable quicker, but it is important to remember that the ligaments might not be fully healed even though the pain has subsided.

The Chiro Approach:

The Initial Stage of Chiropractic treatment

•The aim is to reduce inflammation and improve mobility The treatment frequency is in most cases 3 times over 10 days or until the pain and inflammation begins to subside. The acute pain tends to settle down within 3-6 treatments.

In the early part it can be very useful to use a sacroiliac belt to support the pelvis, especially if the sacroiliac joint is severely inflamed and unstable.
Ice packs are used regularly to reduce the pain, joint inflammation and muscle spasm.
Spinal manipulation or adjustments are used to areas of the spine with restricted movement, to increase mobility and reduce pain.

Massage, soft tissue therapy, ultrasound and interferential therapy may also be used.
Patients are advised to take ‘active rest’, which means to avoid activities which the patients find aggravating but to keep moving around regularly. Prolonged bed rest has been shown to actually prolong back pain. It is best to alternate rest with walking around.

The chiropractor will also give advice on how to get comfortable, how to move, and taught which exercises to do to get comfortable and help you to get on with your life as comfortably as possible.

The Stabilisation Stage of Chiropractic treatment

•The aim is to normalise function and improve strength

As the pain starts to subside, treatments will be gradually spaced out to once a week, once every two weeks etc and you will be given more exercises to do at home.
Specific chiropractic manipulation and soft tissue techniques will be targeted at areas of restricted movement in the low back and surrounding joints, to increase the mobility and optimise spinal function.
Core muscle exercises will gradually be introduced to create better spinal control and stability, which is one way of preventing the injury from coming back.
You will also be giving postural and ergonomic advice to help you reducing the risk of injury.
Doing your exercises long term will be extremely important to create more support and stability for the spine. In some cases ‘curing’ the problem might not be possible, but the goal of the treatment will be to make sure the problem stays manageable, allowing you to do your normal daily activities.

Click Below:
*Consult Your Therapist Before Undertaking Any Exercise Programme!

SI Exercises:

If you are looking to do exercises for sacroiliac joint pain then your first focus should be to stabilize the pelvis including the sacrum in proper alignment.

DO NOT do SI joint exercises in poor pelvic alignment, you will only stabilize the faulty alignment and cause more problems!

FIRST

Learn neutral spine: Neutral Spine is the healthiest and most stable position for the spine and pelvis taking in to account the natural curvature of the spine. Standing: Back up against a wall with your buttocks and shoulder blades leaning into the wall. Notice whether your lower back is against the wall or if there is an excessive arch there. The latter is more common.
To achieve neutral keep the buttocks and shoulders against the wall and then draw the middle part of your back into the wall. You should feel the abdominal muscles engage and/or the ribs drawing in.

•Lying: Lying on a mat with your knees bent and feet hip width apart, arms at your side.
Begin by releasing your tailbone down creating an arc in the lower back, move up into the mid back and draw it down without flattening the spine. The shoulder blades are down and heavy and the back of the neck is long, do this by drawing your chin down towards your chest leaving the size of a fist space there.
•Sitting: When sitting in a chair press your bottom right up against the back of the chair then stack the rest of the spine over it. Your collarbone is over your hip bones and your breastbone is right above the pubic bone. Navel drawn in gently.
Proper posture is the best way to reduce tension from sitting at work all day, on computers, driving, etc.

SECOND

Pelvic Stabilization Exercises for Sacroiliac Joint Pain:

Wall squats

Position: Standing in neutral against the wall with your feet the length of your thighs away from the wall.

Action: Bend your knees no lower than a 90 degree angle keeping your weight in the heels evenly for both feet. Kneecaps should line up with the second toe in each foot. Repeat for 8-12 repetitions. Do 2-3 sets every other day.

Cues: Place hands on hip bones and make sure they stay level as you bend and lift, also keep the buttocks, shoulder blades, and mid part of the back against the wall throughout the exercise.

Pelvic clocks

Position: Lying on the floor with neutral spine and knees bent.

Action: Imagine your pelvis as a clock. 12 o'clock is at your navel, 6 is at your pubic or tailbone, 3 and 9 are the hip bones. Now imagine there is water in that clock or bowl and you are going to empty from 12 o'clock around clockwise and then counter clockwise feeling each number on the clock working.

Cues: Keep the knees still you are just mobilizing the pelvis.

Diaphragmatic Breathing

Position: Lying in neutral spine.

Action: Without changing the position of your spine inhale deeply through the nose filling up or expanding into the ribs and upper back, then exhale through your mouth expelling the air again without changing the spine. On the exhale feel all the air leave your body feeling the muscles tighten around the waist as your abdomen flattens.

THIRD

Strengthening Exercises for Sacroiliac Joint Pain: Once you have a stable and aligned pelvis you can begin mobilizing exercises to continue strengthening.

Leg Circles

Position: Lying on the floor with one leg extended along the mat and the other at a 90 degree angle to the floor and a neutral spine.

Action: Keeping the pelvis still circle the thigh (leg) in the hip socket 6 times each direction. Switch legs.

Cues: Focus on keeping the torso and leg on the mat very still as you freely circle the leg in the air.

Bridges

Position: Lying in neutral with knees bent arms at your side.

Action: Inhale to prepare and exhale as you press into your heels lifting the pelvis up in neutral until weight is between shoulder blades not in the neck. Inhale hold then exhale to bring the tailbone and ribs down all at one time.

Cues: Focus on the navel drawn in to lift the pubic bone up to the ceiling. Weight even in the feet.

Rotation and side bending exercises can be added as you are symptom free in neutral spine.

Comments

Frozen Shoulder Syndrome

2009-06-29T18:10:44+02:00

Adhesive Capsulitis, also known as Frozen Shoulder is a condition that causes restriction of motion in the shoulder joint. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason. Frozen shoulder causes the capsule surrounding the shoulder joint to contract and form scar tissue.

What causes frozen shoulder?

Most often, frozen shoulder occurs with no associated injury or discernible cause. There are patients who develop a frozen shoulder after a traumatic injury to the shoulder, but this is not the usual cause. Some risk factors for developing a frozen shoulder include:

Age & Gender
Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men.

Endocrine Disorders
Patients with diabetes are at particular risk for developing a frozen shoulder. Other endocrine abnormalities, such as thyroid problems, can also lead to this condition.

Shoulder Trauma or Surgery
Patients who sustain a shoulder injury, or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilisation, the risk of developing a frozen shoulder is highest.

Other Systemic Conditions
Several systemic conditions such as heart disease and Parkinson's disease have also been associated with an increased risk for developing a frozen shoulder.

What happens with a frozen shoulder?

No one really understands why some people develop a frozen shoulder. For some reason, the shoulder joint becomes stiff and scarred. The shoulder joint is a ball and socket joint. The ball is the top of the arm bone (the humeral head), and the socket is part of the shoulder blade (the glenoid). Surrounding this ball-and-socket joint is a capsule of tissue that envelops the joint.

Normally, the shoulder joint allows more motion than any other joint in the body. When a patient develops a frozen shoulder, the capsule that surrounds the shoulder joint becomes contracted. The patients form bands of scar tissue called adhesions. The contraction of the capsule and the formation of the adhesions cause the frozen shoulder to become stiff and cause movement to become painful.

A frozen shoulder causes a typical set of symptoms that can be identified by your doctor. The most important finding is restricted movement. Other shoulder conditions can cause difficulty with movement of the shoulder, such as a rotator cuff tear; therefore it is important to have an examiner familiar with this condition for a proper diagnosis.

What are the typical symptoms of a frozen shoulder?

 Shoulder pain; usually a dull, aching pain
 Limited movement of the shoulder
 Difficulty with activities such as brushing hair, putting on shirts/bras
 Pain when trying to sleep on the affected shoulder

What are the stages of a frozen shoulder?

 Painful/Freezing Stage
This is the most painful stage of a frozen shoulder. Motion is restricted, but the shoulder is not as stiff as the frozen stage. This painful stage typically lasts 6-12 weeks.

 Frozen Stage
During the frozen stage, the pain usually eases up, but the stiffness worsens. The frozen stage can last 4-6 months.

 Thawing Stage
The thawing stage is gradual, and motion steadily improves over a lengthy period of time. The thawing stage can last more than a year.

What tests are needed to diagnose a frozen shoulder?

Most often, a frozen shoulder can be diagnosed on examination, and no special tests are needed. An x-ray is usually obtained to ensure the shoulder joint appears normal, and there is not evidence of traumatic injury or arthritic changes to the joint. An MRI is sometimes performed if the diagnosis is in question, but this test is better at looking for other problems, rather than looking for frozen shoulder. If an MRI is done, it is best performed with an injection of contrast fluid into the shoulder joint prior to the MRI. This will help show if the capsule of the shoulder is scarred down, as would be expected in patients with a frozen shoulder.

Frozen shoulder treatment primarily consists of pain relief and physical therapy. Most patients find relief with these simple steps, although the entire treatment process can take several months or longer.

 Exercises and Stretching
Stretching exercises for frozen shoulder serves two functions:
 First, to increase the motion in the joint
 Second, to minimize the loss of muscle on the affected arm (muscle atrophy)

The importance of stretching and exercises cannot be overemphasized as these are the key to successful frozen shoulder treatment. Patients cannot expect to have successful frozen shoulder treatment if they perform exercises only when working with a therapist. These exercises and stretches must be performed several times daily.

 Moist Heat
Applications of moist heat to the shoulder can help to loosen the joint and provide relief of pain. Patients can apply moist heat to the shoulder, then perform their stretching exercises--this should be done at least three times daily. Moist heat can be applied by using a hot-soaked washcloth on the joint for 10 minutes before stretching.

 Physical Therapy
Physical therapists can help a patient develop a stretching and exercise program, and also incorporate ultrasound, ice, heat, and other modalities into the rehabilitation for frozen shoulder. As said previously, it is important that patients perform their stretches and exercise several times daily-not only when working with the therapist.

 Anti-inflammatory Medications
Anti-inflammatory medications have not been shown to significantly alter the course of a frozen shoulder, but these medications can be helpful in offering relief from the painful symptoms.

 Cortisone Injections
Cortisone injections are also commonly used to decrease the inflammation in the frozen shoulder joint. It is unclear the extent of the benefit of a cortisone injection, but it can help to decrease pain, and in turn allow for more stretching and physical therapy. What is known, is the cortisone is only effective when used in conjunction with physical therapy for the management of a frozen shoulder.

Will I need surgery for frozen shoulder?

If the above treatments do not resolve the frozen shoulder, occasionally a patient will need to have surgery. If this is the case, the surgeon may perform a manipulation under anaesthesia. A manipulation is performed with the patient sedated under anaesthesia, and the doctor moves the arm to break up adhesions caused by frozen shoulder. There is no actual surgery involved, meaning incisions are not made when a manipulation is performed.
Alternatively, or in conjunction with a manipulation, an arthroscope can be inserted into the joint to cut through adhesions. This procedure is called an arthroscopic capsular release. Surgical capsular release of a frozen shoulder is rarely necessary, but it is extremely useful in cases of frozen shoulder that do not respond to therapy and rehab. If surgery is performed, immediate physical therapy following the capsular release is of utmost importance. If rehab does not begin soon after capsular release, the chance of the frozen shoulder returning is quite high.

Will my shoulder motion return to normal?

Most patients who have a frozen shoulder will have slight limitations in shoulder motion, even years after the condition resolves. However, this limit in motion is minimal, and often only noticed when performing a careful physical examination. The vast majority of patients who develop a frozen shoulder will recover their functional motion with therapy and stretching alone.

Sources:
Warner, JJ. "Frozen Shoulder: Diagnosis and Management" J. Am. Acad. Ortho. Surg., May 1997; 5: 130 - 140.
Griggs, SM; Ahn, A; Green, A. "Idiopathic Adhesive Capsulitis: A Prospective Functional Outcome Study of Nonoperative Treatment" J. Bone Joint Surg. Am., Oct 2000; 82: 1398.
Rizk, TE; Pinals, RS; and Talaiver, AS. "Corticosteroid injections in adhesive capsulitis" Arch. Phys. Med. and Rehab., 72: 20-22, 1991.

Comments

Thoracic Outlet Syndrome

2009-06-15T16:04:15+02:00

This condition is a controversial diagnosis, since it deals with nerve compression.

Chronic pinched nerves are rarely caused by a structural abnormality, as indicated in the TOS diagnosis, so patients are advised to be vigilant for signs of a misdiagnosed back pain syndrome.

Thoracic Outlet Syndrome is most commonly blamed on impingement of the various neurological structures which compose the brachial plexus. The brachial plexus is a network of nerve tissue stemming from the spinal nerve roots at C5 through T1, which bring nerve messages to the parts of the neck, shoulders and upper back regions.

This most often diagnosed form of the pain syndrome is called neurogenic TOS. Less commonly, vascular tissue is implicated in the compression process, typically the subclavian artery or subclavian vein. This far less common cause of symptoms is referred to as arterial or venous TOS. Occasionally, some patients might be diagnosed with both the neurogenic and arterial/venous forms at the same time.

TOS can result from a back injury such as sports trauma or a car accident TOS can also come about gradually or spontaneously, even though no trauma has been endured. These idiopathic forms of TOS are even more likely to be misdiagnosed and typically turn out to be regional ischemia syndromes caused by a psycho-emotional process. Abnormalities with the scalene muscles have been linked to TOS development, but this is no surprise, since medical science always looks to a structural source for all physical pain, even when the anatomical condition might be purely coincidental and innocent of symptomatic expression. Enlargement (hypertrophy), overuse or injury to the scalene muscles does seem to have some bearing as to who might develop TOS, but is not a factor in all patients.

Symptoms

Symptoms of TOS vary from patient to patient and from causation to causation. Typically, there is pain, stiffness and loss of mobility, functionality and range of motion in the neck, shoulder and upper back. There might be pain in parts of the upper chest or underarm region. Patients might also experience radiating neurological symptoms in the neck, shoulder, arms and hands, such as tingling, weakness and numbness. Arterial or venous forms of the condition might demonstrate a weak pulse in the affected arm and wrist. Certain activities or postures typically worsen or relieve symptoms, although in many cases, this can merely be a conditioned response. TOS is more prevalent in woman than in men and is particularly common in athletes, office workers, people with bad posture and workers with repetitive motion jobs.

Advice

TOS certainly exists, mostly due to obvious trauma. Even minor muscular injuries near the brachial plexus can cause TOS symptoms, although most of these issues should resolve in a few days to a few weeks. Long term structurally induced TOS is rare and generally might indicate a possible mistaken diagnosis.

Tension Myositis syndrome in the upper back and lower neck is generally diagnosed as TOS almost 100% of the time. Obviously, this often leads to treatment resistant pain, which plagues the medical community, as patients continue to suffer despite a battery of seemingly appropriate, but unsuccessful treatment options.

Physical therapy, such as Osteopathy and Chiropractic are the most common conservative treatment options. Injection therapy is common as a next line of defence, along with the ever present pain management drugs which rule the back pain therapy industry. Surgery is sometimes used in extreme or long term cases, but should be avoided unless there is no other option and the diagnosis is confirmed with 100% certainty…

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Some Alternative Approaches to Injury Rehabilitation

2009-06-10T14:06:39+02:00

If you are suffering from a sport related injury or have been injured in an accident, the chances are you will require some professional medical treatment to help you to recover more quickly and more fully from your injuries.

In most cases, this rehabilitation will take the form of either physiotherapy, osteopathy or chiropractic (for moderate injuries such as whiplash and other soft tissue damage) or surgical procedures (to help broken bones to heal more cleanly or to repair damage to ligaments that may have been torn in an accident. However in an increasing number of injured patients are also receiving alternative rehabilitation therapies, often with very positive results.

Pilate's, the full body conditioning technique developed in 1920's Germany to help injured soldiers recover, is one of the most widely used alternative rehabilitation technique for accident victims. Although it was designed to benefit all areas of the body, Pilate’s works particularly well for injuries to the knees, neck, back, hips, shoulders and also for rehabilitation following surgery. As the exercises involved are mainly performed whilst sitting or reclining, Pilate’s is very useful for people who may not be able to stand or support much weight after an accident.

Another alternative form of rehabilitation that is offered to some patients is a pain management program. These programs aim to provide relief for people suffering from chronic pain conditions after an accident or other injury. In many chronic pain conditions, it might be the case that the sufferer is continuing to feel the pain of an injury even after the injury has healed and the physical evidence has disappeared. This might be because pain receptors in the body are still transmitting the sensation of pain to the brain. Pain management programmes aim to treat the pain itself, rather than any underlying injury, which might be treated separately or which might have healed already.

Pain management programs might prescribe medicines to reduce pain or to target problems with the way the sufferer’s brain is interpreting the pain signals, these medicines can include painkillers, anti-depressants and anti-convulsants. On the other hand they might involve the use of physical therapies and exercise routines.

A third approach would be to look at the way the sufferer thinks about the pain and how it affects their mental well being, which can be done using psychological techniques such as biofeedback and cognitive behavioural therapy. The goal of all these treatments is to help people to experience a pain-free life, so that they can return to work and carry out day-to-day tasks, which can have benefits, themselves.

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Osteoporosis "The Silent Disease"

2009-06-01T11:56:17+02:00

The Silent Disease is the name that is often given to Osteoporosis, as most people don't know they have osteoporosis until it has progressed often to the point of fracture, usually in the hip, wrist or spine. Even when undiagnosed osteoporosis results in a vertebral fracture, the pain is frequently dismissed as general back pain.

This lack of awareness can lead to serious illness, deformity and even death.

Osteoporosis alone does not cause back pain. It can, however, weaken the spine to where it is no longer able to withstand normal stress or minor trauma, resulting in vertebral fracture. It is the ensuing fracture that causes pain.

Osteopenia is a condition where bone mineral density is lower than normal, but not low enough to be classified as osteoporosis. While often a precursor to osteoporosis, not everyone with osteopenia will develop osteoporosis. Since a diagnosis of osteopenia puts one at greater risk for osteoporosis, patients are encouraged to seek the advice of their physicians about implementing preventive measures.

Osteoporosis Causes and Risk Factors

Bones are made of complex, constantly changing, living tissue and they are able to grow and heal, and are also susceptible to changes in diet, body chemistry, and exercise levels.

Early in life, more bone is laid down than is removed by the body. People typically achieve peak bone mass by around age 30, after which more bone is lost than is replaced. Too much bone loss leads to osteoporosis.

Both of the two primary types of osteoporosis are far more common in women than men:

Type I osteoporosis (postmenopausal osteoporosis) -generally develops after menopause, when estrogen levels drop precipitously, leading to bone loss - usually in the trabecular (spongy) bone inside the hard cortical bone.

Type II osteoporosis (senile osteoporosis) - typically happens after age 70 and involves a thinning of both the trabecular (spongy) and cortical (hard) bone.

In addition, certain medications and medical conditions can damage bone and lead to what is known as "secondary osteoporosis". Patients being treated for any of the following conditions should discuss the risk of osteoporosis with their physicians:

Endocrine disorders

Marrow disorders

Collagen disorders

Gastrointestinal disorders

Seizure disorders

Eating disorders (such as anorexia or bulimia)

It is important to distinguish between primary and secondary causes of osteoporosis because treatment is often different. To determine the cause, a thorough medical history, physical examination, and appropriate diagnostic tests need to be conducted (see Diagnosing Osteoporosis).

Key risk factors for developing osteoporosis include:

Advanced = age over age 65.

Gender = Women are four times more likely to develop osteoporosis than men.

Heredity = Family history of osteoporosis or fracture on the mother's side.

Personal history = any type of fracture after age 45.

Race = Caucasian and Asian women are at greater risk.

Body type = small-boned women weighing less than 127 pounds.

Menstrual history = Normal menopause increases the risk of osteoporosis and early menopause can exacerbate this risk.

Lifestyle = calcium and/or vitamin D deficiency; little or no exercise especially weight-bearing exercise); alcohol abuse; smoking; too much cola/soda.

Testosterone deficiency (hypgonadism) = in men.

Why women are at greater risk for developing osteoporosis

Estrogen plays an important part in maintaining bone strength. Starting at about age 30 through onset of menopause, women lose a small amount of bone every year as a natural part of the ageing process. When women reach menopause and estrogen levels decrease, the rate of bone loss increases for approximately 8 to 10 years before returning to premenopausal rates.

Osteoporosis Symptoms

Osteoporosis can go undetected for years and fracture is typically the first outward sign.

Advanced osteoporosis is potentially disabling, often leading to one or more of the following:

Fractures of the spine, wrist or hip

Spinal deformity (e.g., lost height, hunched back)

Chronic or severe pain

Limited function and reduced mobility

Loss of independence

Decreased lung capacity

Difficulty sleeping

Osteoporosis is the leading cause of spine fractures, especially in women over age 50, but only about one third of all spine fractures are diagnosed.

Most osteoporotic spine fractures (vertebral compression fractures) start with sudden back pain, usually after routine activity (lifting or bending) that slightly strains or jars the back. After a month or two, this acute pain is usually replaced by an achy pain (see Diagnosing vertebral compression fractures).

Osteoporosis Prevention

Postmenopausal ( Type I ) osteoporosis can be significantly influenced by preventive measures. Most of these behaviours are up to the individual and should be started as early in life as possible. For those genetically predisposed to osteoporosis, the following practices are even more important:

Exercise regularly weight-bearing exercises (activities that work one's bones and muscles against gravity) are essential to maintaining bone health.

Ensure adequate calcium intake, Calcium plays a key role in keeping bones strong. Vitamin D is also essential, as it helps ensure absorption and retention of calcium in bones. Calcium and vitamin D requirements vary depending on age and gender.

Eat a balanced, healthy diet Certain foods provide excellent sources of calcium, while diets high in protein and/or sodium increase calcium loss.

Quit smoking - Smoking has a detrimental effect on bone density, leading to greater risk of injury and longer recovery times.

Limit alcohol consumption - While the exact way alcohol affects bone isn't entirely understood, excessive alcohol use has been proven to accelerate bone loss.

Limit intake of colas/sodas - recent research indicates that too much cola or soda can increase the risk of osteoporosis.

Undergo bone density testing - every 1-2 years if you are postmenopausal, over age 65, or have other risk factors. Bone mineral density (BMD) tests indicate normal, low or osteoporotic bone density levels, as well as any increased risk of fracture.

For more information, see How to prevent osteoporosis.

Osteoporosis Treatment

Once osteoporosis has been diagnosed, patient and physician should work together to develop a treatment plan where the goal is to slow bone loss and prevent fractures. Treatment may include:

Education on diet/nutrition - see Food for Thought: Diet and Nutrition for a Healthy Back.

Exercise (if no fracture) - to help maintain bone density and reduce the risk of falls.

Medication - to slow bone loss and prevent fractures. Osteoporosis medications fall into two categories:

Medications that slow or stop bone resorption (loss);

Medications that increase bone formation.

Treatment for vertebral fractures, which may include:

Rest, though long-term rest accelerates bone loss;

Rigid back braces to support the spine;

Ice/heat and pain medications;

Surgery (kyphoplasty or vertebroplasty), which may be necessary in certain situations where the fracture is causing severe pain and/or deformity, or has failed to respond to three months of non-surgical treatment.

Do be positive because even once osteoporosis has been diagnosed, it is possible to slow bone loss, build bone density and prevent fractures. Continually advancing osteoporosis and related fractures are not an inevitable outcome of being diagnosed with osteoporosis.

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Coping With Headaches

2009-05-31T17:31:49+02:00

It's 6:00 p.m. You've just left work and all you can think about is how much you have to do when you return tomorrow. And before you can get home to try and relax, you have to fight bumper-to-bumper traffic.
Often, a stressful day like this goes hand-in-hand with a headache. But not all headaches are caused by stress.
Learn what could be causing your headaches and the best way to head off the pain.

Tension headaches

Symptoms: Mild to moderate aching pain on both sides of your head. You may also feel tightness in your neck, shoulders, face, and scalp.

Why you hurt: Occasional tension headaches are often related to stress, anxiety or frustration. When you're under stress, the muscles in your face, neck, and jaw contract, sometimes resulting in a headache. In other cases, poor posture such as hunching over at your desk or computer may cause muscle tension that leads to a headache. Daily or chronic tension headaches may be related to a chronic state of anxiety or depression.

What you can do: For occasional tension headaches, taking an over-the-counter pain reliever such as acetaminophen, aspirin, or ibuprofen usually does the trick. Be careful to follow the label instructions, and consult your doctor or pharmacist if you have any questions. Exercise, relaxation techniques, massage, and warm compresses may also ease the pain. If you have chronic tension headaches, consult your doctor for evaluation and treatment options.

Eyestrain headaches

Symptoms: Mild pain in your forehead.

Why you hurt: Straining your eyes may cause muscle contractions that result in a headache.
What you can do: Read in a well-lit area and have your eyes examined regularly. Sometimes, eyestrain signals a need for glasses or a new prescription. If you work at a computer for long periods of time, take frequent breaks to rest your eyes. Look away from the computer and focus on something more than 6 feet away every 10 to 20 minutes. Adjust your monitor so that it's about one arm's length in front of you. If necessary, increase the font size for easier reading.

Migraine headaches

Symptoms: Throbbing pain on one or both sides of your head that worsens with activity. The headache may be accompanied by nausea and vomiting, as well as sensitivity to light and sound. The pain may last from four to 72 hours. You may have a warning or "aura" that a headache is coming, during which you see wavy lines or bright lights or have a blind spot. You may also experience emotional changes, such as depression, several hours or days before the headache strikes.

Why you hurt: Migraines are caused by an initial constriction of blood vessels in the head, followed by a dilation of these blood vessels. Migraines are more common in women, and they tend to run in the family. For some people, various substances can trigger migraines, including chocolate, aged cheeses, alcohol, citrus fruits, monosodium glutamate (often found in Chinese food), nuts, sulfites, and nitrates (commonly found in hot dogs and lunch meats). Many other factors -- including hormonal fluctuations, stress, and a change in sleep patterns can also trigger migraines.

What you can do: As much as possible, avoid anything that triggers your migraines. If you're not sure of your triggers, keep a headache diary. Jot down a list of factors or circumstances about each particular headache and look for patterns or specific triggers. Taking acetaminophen, ibuprofen or aspirin may relieve some of the pain. Again, be careful to follow the label instructions, and consult your doctor or pharmacist if you have any questions. When over-the-counter pain relievers aren't effective, prescription medications may help prevent an oncoming migraine or cut it short. Consult your doctor for help. A technique called biofeedback -- the process of voluntarily controlling bodily functions, such as blood pressure, muscle tension, or heart rate, to improve health and performance -- may be beneficial as well.

Cluster headaches

Symptoms: Episodes of intense, steady pain, often behind one eye. Sometimes the pain is felt above the eye or near the temple. Cluster headaches may be accompanied by symptoms such as tearing, reddening of the eye, drooping or swelling of the eyelid, constriction of the pupil, nasal stuffiness, runny nose, and facial sweating. These symptoms appear on the same side as the headache. Restlessness is also common during a cluster headache, typically lasting from 15 minutes to three hours.

Why you hurt: Although there's no known cause, cluster headaches can be triggered by alcohol, nitrates, and certain stages of sleep during a cluster episode. Cluster headaches may occur at exactly the same time every day for weeks or months, and then not return for months or even years. They may also be seasonal, often striking during spring and autumn. Cluster headaches are most common among men in their 20s to 50s.

What you can do: Generally, prescription medications are needed to prevent a cluster headache or stop one that's in progress. If you're experiencing cluster headaches, consult your doctor for diagnosis and treatment.

Take headaches seriously

Nearly everyone experiences headaches at some point. Although most headaches aren't serious, it's important to be cautious. Seek medical attention if you develop:
 a sudden or intense headache
 a headache that begins during exertion, such as exercise or sex
 a headache associated with fever, stiff neck, rash, or other neurological symptoms
 headaches that become progressively more severe
 a significant change in a previous headache pattern
 headaches that don't respond to treatment

Comments

Rheumatoid Arthritis Diagnosis

2009-05-27T13:35:58+02:00

Do you think that you may have Arthritis?

There are more than 100 different types of arthritis, and each has its own treatment. And, there are other conditions that can cause similar symptoms.

To help evaluate the condition, the GP will want to know about the type of pain or discomfort you've been experiencing. How often and when does it occur? How intense is it? What parts of your body does it affect the most? What seems to cause it to worsen? Are there symptoms that accompany it, such as fever? And, what seems to help it get better?

It would be a great help if you kept an arthritis diary for a couple of weeks to document your pain or discomfort, as well as other factors that may be related. Write down information about what you eat, activities, medications including over-the-counter drugs and vitamins, how much sleep you get and even what the weather is like each day. Take your diary with you to your GP, as it will assist your doctor to determine the best course of treatment for your situation.

Further Tests for Rheumatoid Arthritis

No one-lab test can diagnose rheumatoid arthritis. Instead, rheumatoid arthritis is diagnosed by symptoms and physical signs and by eliminating other diseases that can cause similar symptoms. Physical signs include joint swelling or tenderness. Symptoms that help in diagnosis are stiffness and pain in the same joints on both sides of the body (symmetrical), morning stiffness, and development of rheumatoid nodules.

Diagnosis is based on a set of classification criteria for rheumatoid arthritis.

The following tests may be done to evaluate your symptoms, to rule out other problems, or to monitor treatment:

 Complete blood count (CBC)
 Erythrocyte sedimentation rate (ESR) (may help to assess disease activity)
 C-reactive protein (may help to assess disease activity)
 Rheumatoid factor (RF)
 Antinuclear antibody assay (ANA)
 Anti-CCP (cyclic citrullinated peptide) antibody test (helps confirm diagnosis and may show your risk of having severe symptoms)
 Joint fluid analysis
 Tissue type (human leukocyte antigen) test
 X-rays

Other tests may be done to check for side effects of treatment.

These tests may include:
 Kidney function tests.
 Liver and muscle enzyme tests.
 Bone density test, to check for bone loss (osteoporosis).
 Eye examination.

Because rheumatoid arthritis can lead to severe joint destruction and disability over time, regular evaluation by a health professional is important to determine whether current treatment is working or needs to be adjusted.

Comments

Marfan Syndrome

2009-05-26T13:14:31+02:00

Marfan Syndrome is a disorder of connective tissue, the tissue that strengthens the body's structures. Disorders of connective tissue affect the skeletal system, cardiovascular system, eyes, and skin.

Marfan syndrome is caused by defects in a gene called fibrillin-1. Fibrillin-1 plays an important role as the building block for elastic tissue in the body.

A problem with this gene leads to changes in elastic tissues, particularly in the aorta, eye, and skin. The gene defect also causes too much growth of the long bones of the body. This causes the tall height and long arms and legs seen in people with this syndrome. How this overgrowth happens is not well understood.

In most cases, Marfan syndrome is inherited, which means it is passed down through families. However, up to 30% of cases have no family history. Such cases are called "sporadic." In sporadic cases, the syndrome is believed to result from a spontaneous new gene defect.

People with Marfan syndrome are usually tall with long, thin arms and legs and spider-like fingers-a condition called arachnodactyly. When they stretch out their arms, the length of their arms is much greater than their height.

Other symptoms include:
• Coloboma of iris
• Flat feet
• Funnel chest (pectus excavatum) or pigeon breast (pectus carinatum)
• Highly arched palate and crowded teeth
• Hypotonia
• Learning disability
• Movement of the lens of the eye from its normal position (dislocation)
• Nearsightedness
• Scoliosis
• Small lower jaw (micrognathia)
• Thin, narrow face

A GP will perform a physical examination.
There may be hypermobile joints and signs of:
• Aneurysm
• Collapsed lung
• Heart valve problems

An eye exam may show:
• Defects of the lens or cornea
• Retinal detachment
• Vision problems

The following tests may be performed:

•Echocardiogram
•Fibrillin-1 mutation testing (in some people)
An echocardiogram should be done every year to look at the base of the aorta.

Treatment:
Vision problems should be treated when possible. Take care to prevent scoliosis, especially during adolescence.

Medicine to slow the heart rate may help prevent stress on the aorta. Avoid participating in competitive athletics and contact sports to avoid injuring the heart. Some people may need surgical replacement of the aortic root and valve.

People with Marfan syndrome should take antibiotics before dental procedures to prevent endocarditis. Pregnant women with Marfan syndrome must be monitored very closely because of the increased stress on the heart and aorta.

Prognosis:
Heart-related complications may shorten the lifespan of people with this disease. However, many patients survive well into their 60s. Good care and surgery may extend the lifespan further.

*Experts recommend genetic counseling for couples with a history of this syndrome who wish to have children.

Support: National Marfan Foundation -- www.marfan.org

Comments

Breast Size and Thoracic Spinal Pain.

2009-05-19T14:43:34+02:00

Back pain, including thoracic spinal pain, is a common, potentially disabling, routine presenting complaint to general practitioners. Macromastia is the state of having disproportionately large breasts. Some macromastic women report breast pain and other symptoms, and the intuitively logical assumption is that breast size is the key influence on clinical presentation. Clinical symptoms attributed to macromastia include neck, thoracic spine and shoulder pain, breast pain, headaches, grooving and associated pain caused by bra straps, intertrigo (inflammation of skinfolds), and ulnar nerve paresthesia.

Breast size and mass changes across the life-span suggesting that macromastic symptoms may occur episodically during particular stages of life. Although these symptoms are widely reported, the relationship between breast size and symptoms is somewhat unclear. Breast mass and breast density appear to be important variables. Most outcome studies of reduction mammaplasties support the view that larger breasts equate to greater health burden and demonstrate this relationship through symptom improvement post-surgery, but a recent review of 59 women who underwent reductions involving the removal of less than 1000 g of breast tissue showed that small reductions in breast mass may result in statistically significant improvements in macromastic symptoms.

Breast-related thoracic spinal pain is thought to result from changes in centre of gravity. Recent research has demonstrated that static spinal posture differs significantly according to breast size. large breasts can increase cervical lordosis and thoracic kyphosis, shift the centre of gravity away from the spine and increase muscular effort required to maintain balance. The research also suggested that large or heavy breasts may also lead to continuous tension on the middle and lower fibres of the trapezius muscle and associated muscle groups.

They estimated that 70% of women wear bras that are incorrect sizes or poorly fitted. It was proposed that elevation of the breasts in a bra increased downward forces on the outer scapula. It was also suggested that the posterior straps of a bra act as pulleys over the shoulders, effectively doubling the total downward pull on both shoulders. Associated neck, shoulder and back pain could then, at least partially, be attributed to fatigue in muscles that reverse scapular depression (eg: trapezius, serratus anterior). Bra-strap pressure is only somewhat linked to bust mass: small busted women with tight straps may experience considerable downward pressure on their shoulders.

Breast size and mass vary throughout life, influenced by hormonal changes, body fat composition, stage of reproductive cycle, and breast pathology. Bra size, when fitted according to defined industry standards, may be used as an estimate of breast size. Across the life span and across the population, bra size is not a consistent measure of breast mass which is most accurately estimated from radiographic measures of volumetric density, but among healthy women who have never been pregnant or experienced breast pathology, bra size is likely to be a consistent measure.

Follow these easy steps to ensure you are shopping for your correct bra size:
Measurement number 1: Measure under your bust line.
Put on your best-fitting, unpadded, under wire bra. Measure underneath the bust line and make sure to measure tightly. Be sure the tape measure is straight across your back.

The general rule of thumb for all measuring is: less than ½”, round DOWN, more than a ½”, round UP. So if your measurement is 32 ¼”, call it 32. Write this number down.

Band Size: Calculate your band size.

If measurement 1 is UNDER 33 inches, add 5 inches. If this number is odd, round up to the next EVEN number. If measurement 1 is OVER 33 inches, add 3 inches. If this number is odd, round up to the next EVEN number. Write this EVEN number down. This is your band size.

Measure over the bust line
Measure over the biggest point of your bust line. This is a looser measurement. Make sure the tape measure is straight. Write this number down.

Cup Size: Calculate your cup size.
First subtract measurement number 1 from measurement number 2. Then consult the following chart to find your cup size.

Comments

Non Surgical "Spinal Decompression"

2009-05-17T16:57:12+02:00

Original Message:
-----------------
From:
Date: Sun, 17 May 2009 04:06:51 -0700 (PDT)To:
Subject: non-surgical spinal decompression question

hello there,

i am trying to find out about non-surgical spinal decompression in the uk.
do you happen to know if anyone does it here? i've seen all sorts of stuff
on the web about it in the states but can't seem to find it here in london.
i'd be most grateful if you'd let me know anything you know about the
therapy. is there perhaps some negative reason why it doesn't seem to be
used in the uk?
i've never had the treatment myself but am interested in it.

yours sincerely,

XXX XXXXXX

----- Original Message ----
From: Spinal Heath UK
To: xxxx@yahoo.com
Sent: Sunday, May 17, 2009 1:52:09 PM
Subject: RE: non-surgical spinal decompression question

For Advice:

Traction therapy has been utilized in the treatment of low back pain for
decades. The most recent incarnation of traction therapy is non-surgical
spinal decompression therapy. This form of therapy has been heavily
marketed to manual therapy professions and subsequently to the consumer.

Only one small randomised controlled trial and several lower level efficacy studies have been performed on spinal decompression therapy.
In general the quality of these studies is questionable.

Many of the studies were performed using the VAX-DÂ® unit which places the patient in a prone position.
Often companies utilize this research for their marketing
although their units place the patient in the supine position.

In Summary:
Only limited evidence is available to warrant the routine use of
non-surgical spinal decompression, particularly when many other well
investigated, less expensive alternatives are available.

If you are seeking a non surgical treatment option for your back condition may I suggest that you get yourself assessed at "The Lulinski Clinic" London.

Comments