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online. URL: http://ods.od.nih.gov/factsheets/folate.

asp. Downloaded January 6, 2006.

Staff. “More Folic Acid Consumption Emphasized,” Nutra-

ceuticals World 8, no. 9 (October 2005): 14–15.

footwear See SHOE CHOICE, SPINAL EFFECTS OF.

foraminotomy In a pinch, this surgical procedure

takes the pressure off spinal nerves, specifically

those exiting through holes in the side of the spine

known as the foramina. For example, a

HERNIATED

DISC or OSTEOPHYTE around the VERTEBRAE may press

or pinch a nerve, causing pain, tingling, or numb-

ness in the corresponding limbs. If

SPINAL STENOSIS

occurs in the

LUMBAR SPINE, weakness may be felt

in the legs and feet, whereas an obstruction in the

CERVICAL SPINE often radiates pain or numbness into

the arms and hands.

Procedure

X-

RAYS or other imaging tests show the problem

area then guide the surgeon in making an inci-

sion. In an article for NeckSurgery.com, Dr. B.

Theo Mellion explained, “Bone from the . . . spine

and joint over the nerve are removed using special

cutting instruments and/or a drill. Thickened liga-

ment, bone spurs and/or bulging discs are removed

to decompress the exiting nerve, which is checked

with a probe to insure adequate space around the

nerve root. . . . Depending on many factors such

as the location of the compressed nerve or sever-

ity of the patient’s symptoms, a foraminotomy

may be combined with other procedures such as

a laminotomy or laminectomy.” If a

LAMINECTOMY

is needed, additional steps may be involved. Oth-

erwise, “when the spine surgeon is satisfied that

ample space has been created around the nerve

root, the muscles and interior tissues are closed in

layers using absorbable sutures.”

Risks and Complications

In assessing potential problems, a SpineUniverse

article stated, “All surgical procedures carry some

risk. The risks from a foraminotomy include the risks

inherent to every operation (i.e. a small risk of infec-

tion, bleeding etc.).” Although rare, “there is a small

risk of injury to the nerve or spinal cord and this

should be discussed specifically with the surgeon.”

Outlook and Lifestyle Modiﬁ cations

Pain can be expected at the surgical site, but most

patients notice immediate improvement. Oth-

ers may find symptoms disappearing gradually. To

ease discomfort during recovery,

PAIN MANAGEMENT

usually includes

NONSTEROIDAL ANTI-INFLAMMATORY

DRUG (NSAID) THERAPY and COLD THERAPY. After

recovery, gradual increase in daily

ACTIVITY and

EXERCISE can aid flexibility and build strength. Phys-

ical therapy may also help to increase the

RANGE OF

MOTION and prevent spinal nerves from getting in a

future pinch.

Mellion, B. Theo, M.D. “Surgical: Foraminotomy,” Neck-

Surgery.com. Available online. URL: http://www.

necksurgery.com/treatment-surgical-foraminotomy.

html. Updated April 20, 2005.

Sekhon, Lali, M.D. and Susan Spinasanta. “Foraminotomy:

Taking Pressure off Spinal Nerves,” SpineUniverse.

Available online. URL: http://www.spineuniverse.

com/displayarticle.php/article554.html. Downloaded

January 5, 2006.

Forestier’s disease See DIFFUSE IDIOPATHIC SKEL-

ETAL HYPEROSTOSIS (DISH).

fractures Broken bones can occur anytime any

place for any age group, but an undue number of

fractures fall onto

ATHLETES, CHILDREN, or ELDERLY

persons. As stated in the article “Fractures” on

the American Academy of Orthopaedic Surgeons

(AAOS) Web site, “Fractures can happen in a vari-

ety of ways, but there are three common causes:

Trauma accounts for most fractures. For example,

a fall, a motor vehicle accident or a tackle during

a football game can all result in a fracture.” Sec-

ondly, “osteoporosis also can contribute to frac-

tures. Osteoporosis is a bone disease that results

in the ‘thinning’ of the bone. The bones become

fragile and easily broken.” Finally, “overuse some-

times results in stress fractures. These are common

among athletes.” Most of the time, an external

device, such as a cast or splint, will assist a bone in

106 footwear

mending properly. However, a bone-crushing blow

may require corrective

SURGERY to affix the bone

with metal screws, plates, or pins.

In considering spinal fractures in need of surgical

repair, a SpineUniverse article said, “When describ-

ing and diagnosing spinal fractures, spine surgeons

divide the spinal column into 3 sections: 1. Anterior

column,” which includes the front portion of the

VERTEBRAE, along with the related ligaments and

discs. “2. Middle column—made up of the posterior

one-half of the vertebral body, disc, and . . . the

posterior . . . ligament. 3. Posterior column—made

up of the facet joints . . . and the interconnecting

ligaments.” Besides the location and bone matter,

the stability of a fracture must be assessed. As the

article explained, “Generally, a fracture is consid-

ered stable if only the anterior column is involved,

as in the case of most wedge fractures. When the

anterior and middle columns are involved, the frac-

ture may be considered more unstable. When all

three columns are involved, the fracture is by defi-

nition considered unstable, because of the loss of

the integrity of the posterior stabilizing ligaments.”

Risks and Complications

The AAOS article “Fracture of the Thoracic and

Lumbar Spine” said, “Fracture of one or more

parts of the spinal column (vertebrae) of the mid-

dle (thoracic) or lower (lumbar) back is a serious

injury usually caused by high-energy trauma like a

car crash, fall, sports accident or act of violence (i.e.,

gunshot wound). Males experience the injury four

times more often than females do.” If the fracture

occurs in the

LUMBAR SPINE or CERVICAL SPINE, mov-

ing the person can cause a spinal cord injury that

results in permanent paralysis, disability, or death.

In discussing the complication of burst fractures,

Dr. Thomas A. Zdeblick said this “is a descriptive

term for an injury to the spine in which the vertebral

body is severely compressed.” In a severe trauma,

“a great deal of force vertically onto the spine” can

crush a vertebra. While a compression fracture has a

wedge shape, a burst fracture goes in all directions.

Therefore, “this is a much more severe injury than

a compression fracture for two reasons. With the

bony margins spreading out in all directions the spi-

nal cord is liable to be injured. The bony fragment

that is spread out toward the spinal cord can bruise

the spinal cord causing paralysis or partial neuro-

logic injury.” If this happens in vertebrae between

the

THORACIC SPINE and lumbar spine, “paralysis of

the legs and loss of control of the bowel and bladder

may result.” To avoid this risk, Dr. Zdeblick said, “At

the scene of the accident, patients complaining of

severe back pain should not be placed into a seated

or flexed position. They should be kept lying flat and

transported in the flat position. A patient who stands

or sits with a burst fracture may increase their neu-

rologic injury.” This may or may not be true of every

fracture, but with a burst fracture, “however, often

the amount of pain that is present is severe enough

that patients know it is a good idea not to walk.”

Amazingly, a burst fracture does not necessar-

ily require surgery. Treatment may require only a

molded turtle shell brace or body cast for eight to

twelve weeks. If surgery is later needed, Dr. Zde-

blick said, “The degree of recovery may depend on

the timing of surgery, the degree of spinal canal

compromise and the stability of the spine. The most

important factor in how much neurologic recovery

occurs is how severe the original injury was.”

Statistics and Studies

To prevent a fracture from happening spontaneously,

medical specialists often focus on

BONE MINERAL DEN-

SITY TEST results, particularly in older women. How-

ever, an article in Geriatrics summarized concerns

about the reliability of those predictors. As the arti-

cle reported, “A large number of women sustained

osteoporotic fractures within 1 year after . . . bone

mineral density (BMD) testing, although they had T-

scores greater than -2.5. . . . Approximately 82% of

the women suffered fractures of the wrist, forearm,

hip, rib, or spine. Nevertheless, just 18% of these

women would have been recommended for treat-

ment if the intervention threshold was set at -2.5 or

less.” In other words, “the study showed that if you

use -2.5 as a treatment threshold, which we believe

many physicians do, you would have missed 82% of

the women who actually fractured.”

Special Aids and Adaptations

In bone-compromising conditions, such as

OSTEO-

POROSIS, OSTEOPENIA, FIBROUS DYSPLASIA, CANCER, or

OSTEOGENESIS IMPERFECTA, a patient can sustain a

VERTEBRAL COMPRESSION FRACTURE simply by getting

fractures 107

out of bed. For people with fair to normal bone struc-

ture, complications from a fracture mainly occur by

exerting too much pressure on the bone too soon.

Often, a broken bone means adapting to crutches or

ORTHOTIC device until the bone has healed, but

those aids rarely include a walking cast. As the AAOS

article “Fractures” explained, “Pain usually stops

long before the fracture is solid enough to handle

the stresses of normal activity. Even after your cast

or brace is removed, you may need to continue lim-

iting your activity until the bone is solid enough to

use in normal activity.” Another complication arises

with muscle weakness or tight ligaments caused by

lack of use. However, the gradual increase of

EXER-

CISE and daily ACTIVITY can restore muscle tissue and

ultimately aid bone strength.

American Academy of Orthopaedic Surgeons. “Fracture

of the Thoracic and Lumbar Spine,” AAOS. Available

online. URL: http://orthoinfo.aaos.org/fact/thr_report.

cfm?Thread_ID=299&topcategory=Spine. Downloaded

January 5, 2006.

———. “Fractures,” AAOS. Available online. URL:http://

orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=

125&topcategory=General%20Information. Down-

loaded January 6, 2006.

Holwerda, Teri and Mary Claire Walsh. “Spinal Fractures:

The Three-Column Concept,” SpineUniverse. Avail-

able online. URL: http://www.spineuniverse.com/

displayarticle.php/article2718.html. Last updated April

1, 2005.

Staff. “Fracture Risk Intervention Relies on More than

T-scores,” Geriatrics 59, no. 7 (July 2004): 16–17.

Zdeblick, Thomas A., M.D. “Burst Fractures: Defined

and Diagnosed,” SpineUniverse. Available online.

URL: http://www.spineuniverse.com/displayarticle.

php/article1434.html. Last updated December 28,

2005.

108 fractures

109

gene therapy

See RESEARCH.

genetic factors, genomics When a person has

amber eyes, black curls, creamy skin, or long fingers,

those genetic factors can be summed up at a glance.

A closer look into that attractive cover may show

an inherited tendency toward art, mathematics,

mechanics, music, or sports. Whether at birth or over

time, genetic factors can also be seen in bone quality,

musculoskeletal development, or a tendency toward

conditions that affect the

BACK and SPINE. For exam-

ple, parents may have spinal concerns for

INFANTS

born into a family history of

ANKYLOSING SPONDYLITIS,

GROWTH HORMONE DISORDERS, OSTEOGENESIS IMPER-

FECTA, OSTEOPOROSIS, or SCOLIOSIS. They may not

know, however, of genetic influences such as iron

metabolism dysfunction that often occurs in patients

with

RHEUMATOID ARTHRITIS or other inflammatory

disorders. With more information, though, people

find more pertinent questions to ask.

An article posted by the Office of Genomics at

the Centers for Disease Control and Prevention

(CDC) defined genetics as “the study of inheritance,

or the way traits are passed down from one gen-

eration to another.” As the CDC explained, “Genes

carry the instructions for making proteins, which

in turn direct the activities of cells and functions of

the body that influence traits such as hair and eye

color. Genomics is a newer term that describes the

study of all the genes in a person, as well as interac-

tions of those genes with each other and with that

person’s environment.”

In “Genomics Lingo,” Elizabeth Mahanna

explained that “genetics usually refers to the

study of single genes, while genomics refers to

the study of all the genes in a person or organism.

The human genome is a person’s complete set of

DNA.” Regarding DNA, she explained, “The chemi-

cal DNA (deoxyribonucleic acid) is in all the cells of

our body. . . . Genes are pieces of DNA that contain

instructions for making cells or for what cells do.

Each gene contains instructions for building one or

more proteins, but a gene can contain millions of

bases, so deciphering how it works or what a muta-

tion is can be very difficult.” Basically, “a mutation

is a change in the order of the bases in a gene.”

Interestingly though, “scientists have found that,

of the 3 billion or so bases in the human genome,

99.9% are exactly the same from person to person.

About 3 million (or 0.1%) are different, and that’s

what makes us unique. Three million may seem

like a big number, but it’s not much compared to

3 billion.” Also, “scientists now think that there

are more genetic differences between people of the

same race than between people of different races.”

Risks and Complications

Many problems affect the back and spine because

of genetic factors. To assess the likelihood of such

occurrences, the Office of Genomics and Disease

Prevention of CDC said, “The key features of a fam-

ily history that may increase risk are: Diseases that

occur at an earlier age than expected . . . ; Disease

in more than one close relative . . . ; Certain combi-

nations of diseases within a family. . . . If your fam-

ily has one or more of these features, your family

history may hold important clues about your risk

for disease.” Therefore, “people with a family his-

tory of disease may have the most to gain from

lifestyle changes and screening tests. . . . You can’t

change your genes, but you can change unhealthy

behaviors, such as smoking, inactivity, and poor

eating habits. In many cases, adopting a healthier

lifestyle can reduce your risk for diseases that run

in your family.”

Statistics and Studies

According to the CDC, “Geneticists have long rec-

ognized the value of family history for diagnosing

disorders due to mutations in single genes, includ-

ing certain forms of common diseases. Although

typically associated with a very high individual

risk of disease, single-gene mutations account for

a small proportion of cases. Most common diseases

result from the interactions of multiple genes with

multiple environmental factors in complex patterns

that, despite progress in sequencing the human

genome, are unlikely to be understood fully in the

near future. In the meantime, family medical his-

tory represents a ‘genomic tool’ that can capture

the interactions of genetic susceptibility, shared

environment, and common behaviours in relation

to disease risk.”

Special Aids and Adaptations

No one wants to experience a disabling deformity,

CHRONIC PAIN, or shortened life span, but parents in

particular just want their children to be happy and

healthy. When genetic factors decrease the likeli-

hood of physical, mental, social, or financial health,

a family may have difficulty accepting a condition

or seeing a child for the individual she or he is. High

genetic factors trigger high emotions, but these can

often be calmed as a genetic counselor or medical

specialist answers questions and overcomes fears

with facts. If someone already faces a spinal disor-

der, that person may find the aid of organizations

who assist with that condition. Clinical RESEARCH

provides an option for adaptation, too, by giving

individuals active means of participating in their

own health and aiding others in finding effective

treatments.

Online information from the March of Dimes

said, “Identifying disease-causing genes can be a

first step toward developing specific treatments,

such as new drugs or gene therapy, in which a

healthy gene is used to replace one that is missing

or faulty.” Furthermore, “knowing more about

our genetic makeup also should lead to a more

individualized approach to preventive medicine.”

For example, “you may be able to be tested to

learn whether you are specially susceptible to

certain diseases, so that you can take steps to pre-

vent them.”

While genetic factors affect everyone in one

way or another, most people have at least some

measure of control through their choices. For

example,

ENVIRONMENTAL INFLUENCES that affect

the back or spine may necessitate a move to a

place deemed healthier for that person. More

often, restorative aids of daily

ACTIVITY, EXERCISE,

ample fresh water,

NUTRITION, and SLEEP can help

people overcome a tendency toward a particular

condition and better adapt to the unique life they

have been given.

Mahanna, Elizabeth. “Genomics Lingo,” Office of Genom-

ics & Disease Prevention, Centers for Disease Control

and Prevention (CDC), Department of Health and

Human Services. Available online. URL: http://www.

cdc.gov/genomics/activities/ogdp/2003/2003_lingo.

htm. Last updated December 30, 2005.

March of Dimes Birth Defects Foundation. “Genetic Science

on the Move,” March of Dimes. Available online. URL:

http://www.marchofdimes.com/pnhec/4439_4134.asp.

Downloaded January 7, 2006.

Office of Genomics & Disease Prevention, Centers for

Disease Control and Prevention. “Frequently Asked

Questions,” CDC, Department of Health and Human

Services. Available online. URL: http://www.cdc.gov/

genomics/faq.htm. Last updated December 30, 2005.

———. “General Public: Family History,” CDC. Available

online. URL: http://www.cdc.gov/genomics/fHix.htm.

Last updated December 30, 2005.

geriatrics See ELDERLY, SPINAL CONCERNS OF THE.

gigantism See GROWTH HORMONE DISORDERS.

glucosamine Found naturally in the body, glu-

cosamine is a type of amino sugar thought to aid

formation of healthy cartilage. Another naturally

occurring substance, chondroitin sulfate is part of a

protein believed to help cartilage elasticity. Together

or separately, synthetic versions of these substances

may be used to treat

OSTEOARTHRITIS (OA).

As a Spine-health article explained, “Perhaps the

most important aspect of glucosamine and chon-

droitin sulfate supplements is that they are thought

110 geriatrics

to help slow or prevent the degeneration of joint

cartilage, the underlying cause of osteoarthritis

pain. Glucosamine and chondroitin sulfate dietary

supplements may also help alleviate existing joint

pain.”

Dosage and Potential Side Effects

In an article for the Cleveland Clinic Journal of Medi-

cine, Dr. Michele Hooper wrote, “Although no

study has addressed the correct dose of glucos-

amine or the actual time to onset of pain relief, the

human clinic trials seem to suggest that a 12-week

course of treatment is required at a dosage of 500

mg three times a day.” People who are allergic to

shellfish may not be able to take glucosamine since

it is derived from crustaceans, but for most people,

“glucosamine is less toxic than nonsteroidal anti-

inflammatory drugs.”

Glucosamine can be extracted from a number of

sources, such as crab, lobster, or shrimp, so people

may react to a product by one manufacturer and

not another. According to the Arthritis Founda-

tion, “In most cases, however, allergies are caused

by proteins in shellfish, not chitin, a carbohydrate

from which glucosamine is extracted. . . . Because

glucosamine is an amino sugar, people with diabe-

tes should check their blood sugar levels more fre-

quently when taking this supplement.”

Adding chondroitin may add other concerns.

For example, “if you are taking chondroitin sul-

fate in addition to a blood-thinning medication

or daily aspirin therapy, have your blood clotting

time checked more often. This supplement is simi-

lar in structure to the blood-thinning drug hepa-

rin, and the combination may cause bleeding in

some people.” Otherwise, the Arthritis Foundation

said, “The most common side effects are increased

intestinal gas and softened stools. If you experience

these problems, you might want to try another

supplement brand before you stop using them alto-

gether.” However, “if you don’t experience any dif-

ference in your symptoms within a few months,

you probably will not get any relief from using the

supplements.”

Patients who cannot tolerate glucosamine sul-

fate might try supplementing with glucosamine

hydrochloride. As a Spine-health article reported,

“Glucosamine hydrochloride, another form of glu-

cosamine, is considered to be equally effective as

the sulfate form. . . . It is absorbed more easily by

the body and can be taken in lower dosages with the

same effectiveness as glucosamine sulfate.”

Statistics and Studies

With new studies underway, the Arthritis Founda-

tion said, “Past studies show that some people with

mild to moderate osteoarthritis (OA) taking either

glucosamine or chondroitin sulfate reported pain

relief at a level similar to that of nonsteroidal anti-

inflammatory drugs (NSAIDs) such as aspirin and

ibuprofen. Some research indicates that the supple-

ments might also slow cartilage damage in people

with OA.”

Arthritis Foundation. “Glucosamine and Chondroitin

Sulfate.” Available online. URL: http://www.arthritis.

org/conditions/alttherapies/Glucosamine.asp. Down-

loaded January 7, 2006.

Hooper, Michele, M.D. “Is Glucosamine an Effective Treat-

ment for Osteoarthritic Pain?” Cleveland Clinic Journal

of Medicine 68, no. 6 (June 2001): 494–495.

Hyde, Thomas E. “Effectiveness of Glucosamine and

Chondroitin Sulfate for Osteoarthritis,” Spine-health.

com. Available online. URL: http://www.spine-health.

com/topics/conserv/gluco/gluco01.html. Posted April

19, 2005.

gold salt treatment Gold salt may offer a dash of

help, especially when such treatments as

NONSTE-

ROIDAL ANTI-INFLAMMATORY DRUG (NSAID) THERAPY

STEROID THERAPY have not eased RHEUMATOID

ARTHRITIS. Considered a second-line drug, gold salts

can be administered in a capsule or as an injec-

tion to reduce inflammation, relieve joint pain,

and lower the likelihood of bone or joint damage.

Either form, however, may take two to six months

to become effective.

Dosage and Potential Side Effects

As a therapy for

JUVENILE RHEUMATOID ARTHRITIS

(JRA), gold salt treatments often start with weekly

injections that taper to bi-weekly then once-a-

month. However, an article for BCHealthGuide

reported, “Gold salts treatment is often discontin-

ued because the shots are painful, testing is necessary

gold salt treatment 111

with every treatment, and reactions to the medi-

cation are common.” If the treatment causes soft

tissue to inflame, this side effect may first become

apparent in a rash or other inflammation of the

skin.

A MedicineNet article cautioned that, “Side

effects of gold salts can occur any time during treat-

ment or months after treatment has been discon-

tinued,” but the treatment “should be avoided by

patients with a history of serious reaction to any

gold medication. . . . It should also be avoided in

patients with blood, liver or kidney diseases, recent

radiation treatment, or uncontrolled diabetes.”

According to information from the University of

Washington (UW) Web site, “When injected, gold

is given as gold sodium thiomalate (brand name:

Myochrysine) or as aurothioglucose (brand name:

Solganal). Injections must be given by your doc-

tor or nurse. First, you’ll be given a small dose, to

make sure you do not have a severe reaction to the

medicine. Then, you’ll gradually be given larger

doses until the full dose is reached. The full dose is

given every week for four to five months. The dose

is then adjusted, depending on how your arthritis

improves and whether you have any side effects.

When things are going well, the periods between

injections will be increased, usually up to four

weeks. Since everyone reacts differently to gold,

some people will require more frequent injections

than other people.” In capsule form, “gold is given

as auranofin (brand name: Ridaura). It is usually

given as two capsules every day. Some doctors

prefer to start treatment with a single capsule for

the first several weeks. You may be given slightly

higher or lower doses from time to time, depend-

ing on the side effects and how well your arthritis

responds.”

Statistics and Studies

To date, studies have not shown the means by

which gold salts work for any age group, but for

CHILDREN under six, neither safety nor effectiveness

has been established. For other

ARTHRITIS or RA

patients, the UW reported, “Two or three of every

10 people do not benefit from gold,” but “arthri-

tis usually improves in about one-half of all people

treated early in the course of the disease. Many

‘late starters’ may also benefit from gold.”

Cooke, Kerry V. and Richard P. Terra. “Gold Salts for Juve-

nile Rheumatoid Arthritis,” BCHealthGuide.org, Brit-

ish Columbia Ministry of Health. Available online. URL:

http://www.bchealthguide.org/kbase/topic/detail/

drug/hw102829/detail.htm. Last updated October 8,

2004.

MedicineNet.com. “Aurothioglucose Center.” Available

online. URL: http://www.medicinenet.com/aurothio-

glucose/article.htm. Downloaded January 7, 2006.

UW Medicine, Orthopaedics and Sports Medicine. “Gold

Treatment.” University of Washington, Seattle. Avail-

able online. URL: http://www.orthop.washington.edu/

uw/medications/tabID__3376/ItemID__76/Articles/

Defau lt.aspx. Last updated December 30, 2004.

graft See BONE GRAFT.

growth hormone (GH) disorders During child-

hood, the pituitary gland produces a growth

hormone that stimulates development of the mus-

culoskeletal system. Too much of this good thing

causes gigantism in

CHILDREN or ADOLESCENTS, and

too little GH causes a type of

DWARFISM. Unlike the

more common form of dwarfism known as achon-

droplasia, the type related to growth hormones

may not be apparent in newborns since the propor-

tions of head, body, and limbs look like those of

most

INFANTS.

Risks and Complications

Usually, parents must decide whether a child with

GH disorder will undergo injections on a weekly

basis or continue as a little person at maturity. Simi-

larly, parents of children with gigantism may be the

ones who elect treatments that slow growth. Either

choice can bring physical and emotional complica-

tions felt throughout the family.

If GH production occurs in a normal manner

until the teen years then becomes excessive in

adult years, a condition known as acromegaly may

result. With acromegaly, the increased production

of GH becomes apparent as hands, feet, and skin

thicken, grow, and eventually, become misshapen.

Also, bony overgrowth in the

SPINE can press spi-

nal nerves, causing

CHRONIC PAIN or numbness in

the limbs. Sometimes this adult form of gigantism

112 graft

occurs from GH stimulation due to a tumor, which,

often, can be surgically removed. If not, treatments

to normalize GH may cause side effects or begin too

late to be effective. Untreated, gigantism and acro-

megaly often result in early death.

A GH deficiency that has been noticed and

treated during childhood may cause complications

in adults when treatments end. Also, GH affects

muscle mass and bone composition throughout life,

so an adult could be more prone to develop such

conditions as

OSTEOPOROSIS or experience adverse

affects of

WEIGHT. To prevent these complications,

follow-up testing will be needed with GH therapy

often resumed during the adult years.

Statistics and Studies

In considering a maintenance dose for GH defi-

ciency during the transition from adolescent to

adult years, Dr. Madhusmita Misra said, “This is an

important question, which has not yet been fully

addressed. Based on higher GH concentrations in

children and adolescents compared with adults,

the replacement dose in children is higher” than

for adults. “The optimal dose during the transi-

tion from adolescent to adult replacement is likely

somewhere in between, given that GH concen-

trations gradually decrease after puberty to adult

levels.” Besides the best dosage, timing may be a

factor. Discontinuation of therapy for a period of

one to three months is advisable prior to re-testing,

but “Current data suggest that the duration of dis-

continuation of GH therapy should not last longer

than two years pending further data.”

GH levels bear watching in patients with an

excess of growth hormones too. To offer some sta-

tistics, an eMedicine.com article said, “Gigantism is

extremely rare, with approximately 100 reported

cases to date. Acromegaly is found more frequently,

with an incidence of 3–4 cases per million people

per year and a prevalence of 40–70 cases per mil-

lion population.” With acromegaly, the mortality

rate may be up to three times higher than a national

average. However, normalization of GH levels usu-

ally brings an average life expectancy.

Special Aids and Adaptations

An adult who has previously had no excess of GH

may encounter overproduction because of a tumor,

or a person can acquire GH deficiency. As Dr. Steven

Grinspoon explained, “Acquired growth hormone

(GH) deficiency results from the destruction of

normal pituitary and/or hypothalamic tissue, usu-

ally from a tumor or secondary to surgical and/or

radiation therapy.” Whether a patient has too much

growth hormone or too little, an endocrinologist or

other specialist can adapt an appropriate course of

treatment for that individual, regardless of the age.

Grinspoon, Steven, M.D. “Advances in Recombinant

Human Growth Hormone Replacement Therapy in

Adults,” The Neuroendocrine Clinical Center, Mas-

sachusetts General Hospital, Harvard Medical School.

Available online. URL: http://pituitary.mgh.harvard.

edu/e-f-944.htm. Downloaded January 9, 2006.

Misra, Madhusmita, M.D. “Growth Hormone Treatment:

Transitioning Care from Adolescence to Adulthood,”

The Neuroendocrine Clinical Center, Massachusetts

General Hospital, Harvard Medical School. Avail-

able online. URL: http://pituitary.mgh.harvard.edu/

NCBV11I2.htm#GH. Downloaded January 9, 2006.

Shim, Melanie, M.D. and Pinchas Cohen, M.D. “Gigantism

and Acromegaly,” eMedicine.com. Available online.

URL: http://www.emedicine.com/ped/topic2634.htm.

Last updated July 29, 2004.

growth hormone (GH) disorders 113

114

heart, effects of the spine on the

Does the SPINE

affect the cardiovascular system? Can

SPINAL MANIPU-

LATION ease chest pain or regulate a heartbeat? Can

cardio-static on the line of a misaligned spine clear up

by adjusting the vertebral joint that connects the neck

to the upper

BACK? Answers to such questions may

stir controversy, yet the heart does not live alone.

With the aid of imaging tools, an inside glimpse into

the cardiovascular system reveals a complex arrange-

ment of blood, spinal nerves, and soft tissue connect-

ing this vital muscle to a variety of protective ribs and

VERTEBRAE. Also, less obvious connections between

the heart and spine can be found.

Chapter 10 of Somatovisceral Aspects of Chiropractic:

An Evidence-Based Approach discussed the relationship

between the heart and various pathways involving

spinal nerves. For example, the vagus nerve with

its cardiac branches extends into and beyond the

THORACIC SPINE, which consists of the vertebrae

numbered T1–T12. Because of this mid-point con-

nection with the spine, stimulating the vagus nerve

will lessen heart muscle contractions and slow the

heartbeat, and “very strong stimulation of the vagi

can cause cardiac arrest for up to 10 seconds.” Fur-

thermore, spinal misalignment or

VERTEBRAL SUB-

LUXATION “may affect the rate, rhythm, and power

of heart contraction through . . . pathways originat-

ing from T1–T5.” In addition, “cervical subluxation

at any level could also affect . . . pathways to the

heart.” For example, if the vertebrae in the

CERVI-

CAL SPINE shift or lose alignment, “the heart could be

disturbed by upper cervical subluxation, primarily

because of the passage of the vagus nerve through

the jugular foramen.”

Risks and Complications

A simple comparison of spinal misalignment might

equate a cardiac problem to a washing machine

with an out-of-balance load. That figurative exam-

ple may or may not hold water, but another meta-

phorical glimpse comes in considering the hose. For

example, a clogging agent, such as the formation of

a blood clot at the site of a spinal injection, could

produce cardiovascular complications that risk

shutting the heart down.

Other cardiac imbalances may occur from some-

thing akin to electric impulses, or the lack thereof,

affecting the natural pacemaker or sinus rhythm

of the heart. An article in the Canadian Journal of

Anesthesia discussed the risks of a spinal injection

inducing a dangerously low heart rate and causing

bradycardia then warned, “Given that bradycardia

can occur at times after subarachnoid injection,

immediate availability of atropine is a wise precau-

tion.” Regardless of the procedure that requires

anesthesia injected into the spine, “deviations from

normal sinus rhythm can be insignificant or have

effects that range from discomfort for the awake

patient to serious morbidity requiring resuscitative

intervention.” Therefore, “the importance of an

arrhythmia lies in its impact on the patient’s cardio-

vascular status.” However, “this may be difficult to

separate from the physiological effects of the spinal

anesthetic itself or the interventions employed to

manage side effects.”

Statistics and Studies

After gathering evidence of studies spanning many

decades, Masarsky and Cremata summarized the

findings. In 1922, for example, “Henry K. Winsor,

a medical anatomist at the University of Pennsylva-

nia, reported autopsy results correlating regions of

spinal curvature to 20 cases of heart . . . pathology.

Spinal curvature was found in the T1–T5 region,”

of the thoracic spine, “in 18 cases, and at C7,” of

the cervical spine through, “T1 in 2 cases.” In 1939,

researcher A. D. Becker reported on manipula-

tive osteopathy in cardiac therapy with particular

emphasis on the upper cervical spine and T1 to T6

vertebrae in the thoracic region. Similarly, in 1961,

Richard Koch presented a review of 150 cases of

heart disease. Reporting highlights from that study,

Masarsky and Cremata said, “In 93% of the func-

tional group and 100% of the organic group, . . .

evidence of vertebral dysfunction was noted in the

T2–T6 region, with findings clustering at T4–6. In

summarizing the histories of these patients, Koch

found that they all experienced upper thoracic

symptoms. Furthermore, the majority of these

patients reported that they developed upper tho-

racic spine symptoms months or years before the

onset of their cardiac symptoms.” More recently,

M. E. Jarmel considered the possible role of spinal

joint dysfunction in the genesis of sudden cardiac

death in a 1989 issue of the Journal of Manipula-

tive and Physiological Therapeutics. Masarsky and Cre-

mata also mentioned a 1995 study by Jarmel and

associates that used a monitoring system to record

improvements of cardiac arrhythmias after manip-

ulation had corrected vertebral shifts in the cervical

or upper thoracic regions of the spine.

Special Aids and Adaptations

To prove and replicate treatments and, thus, aid

health in the cardio-spinal connection, medical sci-

ence requires well-documented evidence. Masar-

sky and Cremata, who are themselves members of

the chiropractic community, mentioned a “treat-

ment package” consisting of spinal manipulation,

EXERCISE, and NUTRITION, but they found scanty

documentation to report the effectiveness of that

package. As they said, “Unfortunately, the levels

of chiropractic adjustment were not noted and the

dietary and exercise programs were not described.”

This loss may be lamentable, not only for individu-

als seeking treatment, but also for those who may

not know to treat the spine as a bodyguard intended

to protect a healthy heart.

Masarsky, Charles S. and Edward E. Cremata. “Chiro-

practic Care and the Cardiovascular System,” Chapter

10, Somatovisceral Aspects of Chiropractic: An Evidence-

pages 143–154. Available online. URL: http://www.

intl.elsevierhealth.com/e-books/pdf/184.pdf. Down-

loaded January 10, 2006.

Youngs, Paul J. and Judith Littleford, M.D. “Arrhyth-

mias during Spinal Anesthesia/ L’arythmie pendant la

rachianesthésie,” Canadian Journal of Anesthesia 47, no.

5 (2000): 385–387.

heat therapy A nice hot bath comes with the con-

notation of soothing relaxation that helps to lessen

pain. Although

COLD THERAPY brings down inflam-

mation and swelling, heat works well in loosening

stiff joints, muscle spasms, and soreness in

PARA-

SPINAL MUSCLES. To obtain this therapeutic value,

some wet and dry options include the use of com-

fortably warm water, electric heating pads, steam

baths, hot tubs, heated cloths, and hot packs with

air-activated discs that retain their warmth for sev-

eral hours. For most people, though, that would be

too long to roast.

Procedure

Regardless of the heat source, the basic procedure

applies warmth wherever something hurts. Excep-

tions include inflammation, bruising, and bleed-

ing, since heat accelerates swelling and blood flow.

Pending the approval of a doctor, some patients may

need to warm an area for hours, but usually 15 to

20 minutes every couple of hours will suffice.

Risks and Complications

Patients with problems of vein fragility or high

blood pressure should avoid heat therapy since the

treatment can increase their symptoms or cause

an adverse event. Anyone with nerve damage or

a cognitive impairment may risk burning the skin.

Also, heat can parch soft tissue, irritate sensitive

skin, and aggravate dermatological eruptions.

Outlook and Lifestyle Modiﬁ cations

In an online article, Dr. Pierre Rouzier said, “Moist

heat is more effective than dry heat because it pen-

etrates more deeply, which increases the effect on

muscles, joints, and soft tissue. . . . Heat can be

used to help loosen tight muscles and joints during

a warm-up period before exercise.”

In an article for Spine-health, Dr. Vert Mooney

discussed the relief heat therapy brings to

LOW

heat therapy 115

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