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in the enzymes that regulate carbohydrates, lipids,
or other metabolic pathways in the muscle fibers.
The most common disorders are related to glyco-
gen storage problems.” With a carnitine deficiency,
however, the body lacks a minuscule molecule
needed for metabolism. Whether that molecule
or an enzyme causes the problem, the result is an
inability to extract energy from nutritious meals.
Symptoms and Diagnostic Path
ACUTE PAIN and muscle spasm or cramping often
produce the first signs with disproportionate fatigue
following a few minutes of
EXERCISE. Since most
people just assume they are out of shape, a diag-
nosis may be a long time coming. Then, an exercise
test,
ELECTROMYOGRAM, muscle biopsy, or other lab
work may confirm a diagnosis.
Treatment Options and Outlook
With no specific treatment recommended, therapy
must be fitted to the individual, who then takes an
active part in lessening the impact of the disease.
For example, a person might practice self-awareness
to determine what triggers and what eases muscle
cramps or pain. Also, foods affect each patient dif-
ferently, but a physician or nutritionist can discuss
the best choices for that particular person.
Risk Factors and Preventive Measures
Overexertion and inadequate meals aggravate the
symptoms and sometimes lead to
RHABDOMYOLY-
SIS. A doctor may recommend light exercises, but
WEIGHT-BEARING EXERCISE and STRENGTH TRAINING
usually prove counterproductive, causing cramps
or spasms and, in rare cases, weakened muscles. To
maintain mobility and independence, a walker or
wheelchair may be needed. However, with a diet
and lifestyle designed for the individual, symptoms
often remain manageable.
Harati, Y., M.D. “Metabolic Myopathies,” Baylor Col-
lege of Medicine. Available online. URL: http://www.
bcm.edu/neurology/research/nmus/nmus3a5.html.
Downloaded January 30, 2006.
Muscular Dystrophy Association. “Facts About Metabolic
Diseases of Muscle,” MDA. Available online. URL:
http://www.mdausa.org/publications/fa-metab-qa.
html. Downloaded January 30, 2006.
microdiscectomy This type of DISCECTOMY sur-
gically treats such conditions as a
HERNIATED DISC,
commonly located in the
LUMBAR SPINE. With up-to-
date technology, the procedure involves
MINIMALLY
INVASIVE SURGERY that can sometimes be done in an
outpatient clinic but may require an overnight hos-
pital stay.
According to an article posted by Back.com,
“Lumbar microdiscectomy is usually recommended
only when specific conditions are met. In general,
surgery is recommended when a ruptured disc is
pinching a spinal nerve root(s) and you have: 1.
Leg pain which limits your normal daily activities.
2. Weakness in your leg(s) or feet. 3. Numbness in
your extremities. 4. Impaired bowel and/or bladder
function.”
Procedure
To describe a lumbar microdiscectomy, information
from Holy Cross Hospital said, “A microdiscectomy
is performed through a very small incision—usu-
ally only one to one-and-a-half inches in the
lower back. In the procedure, a small portion of
the bone over the nerve root and/or disc material
from under the nerve root is removed to relieve . . .
impingement and create more room for the nerve
to heal. Because the procedure leaves nearly all of
the joints, ligaments, and muscles intact, it does not
change the mechanical structure of the patient’s
spine.”
In a paper presented to the American Academy
of Orthopaedic Surgeons, a group of surgeons com-
pared standard equipment traditionally used for
lumbar microdiscectomy with a minimally invasive
procedure. Both types of surgery use a retractor to
hold back muscle in the surgical site, but the differ-
ences between those tools will affect the procedure.
For instance, “microdiscectomy is typically per-
formed via a small incision utilizing a microscope
for enhanced visualization. With the recent interest
in minimally invasive surgery, tubular retractors
which dilate” or expand “the muscle fibers have
become popular in order to minimize the incision
length, while achieving the same surgical goals.”
After reviewing “sixty-two consecutive patients
who underwent a total of sixty-five procedures over
a 3-year period,” the surgeons concluded, “There
appears to be no significant difference between the
166 microdiscectomy
minimally invasive tubular retractors or standard
retractors for patients undergoing single-level lum-
bar microdiscectomy procedures. There may be a
trend towards a shorter hospital stay and perhaps
a higher rate of persistent symptoms with the use
of the tubular retractors, however, it appears that
both methods are successful and provide similar
clinical results.”
Risks and Complications
With a success rate of 90 to 95 percent, microdis-
cectomy still has the typical surgical risks of bleed-
ing, nerve damage, and infection. Pain will likely
continue for a while too.
In an article for eSpine, Dr. Robert Pashman said,
“It is normal to have some pain after any opera-
tion. After a lumbar microdiscectomy, there may
be some leg ‘aching’ which occurs as the nerve(s)
attempts to heal. You also may feel some muscle
spasms across your back and down your leg(s). And
if there was inflammation in the nerve root, some
pain may persist until this inflammation diminishes.
You will be given appropriate medication to control
your pain, relieve back spasms and reduce inflam-
mation.” Besides common occurrences of pain and
muscle spasm, Dr. Pashman said, “It is not unusual
to feel tired and discouraged for several days fol-
lowing surgery. These feelings may be your body’s
natural reaction to the cutback of extra hormones
it generated during surgery. Although some emo-
tional letdown can be expected, you must not let it
get in the way of your recovery.”
Outlook and Lifestyle Modifi cations
In an article for Spine-health, Dr. Peter F. Ullrich Jr.
wrote, “Some spine surgeons restrict a patient from
bending, lifting, or twisting for the first six weeks
following surgery. However, since the patient’s
back is mechanically the same, it is also reasonable
to return to a normal level of functioning imme-
diately following microdiscectomy spine surgery.
There have been a couple of reports in the medi-
cal literature showing that immediate mobiliza-
tion (return to normal activity) does not lead to an
increase in recurrent lumbar herniated disc.”
To assist healing, patients should refrain from
smoking. Ample water,
SLEEP, NUTRITION, and
appropriate
EXERCISE provide the healthy lifestyle
needed for recovery and also help to avoid future
problems with
DISCS.
Holy Cross Hospital. “Microdiscectomy.” Available on-
line. URL: http://www.holycrosshealth.org/svc_surgery_
microdiscectomy.htm. Downloaded January 30, 2006.
Medtronic Sofamor Danek. “Surgical: Lumbar Micro-
discectomy,” Back.com. Available online. URL: http://
www.back.com/treatment-surgical-microdiscectomy.
html. Downloaded January 10, 2006.
Pashman, Robert, M.D. “Lumbar Microdiscectomy,” eSpine.
com. Available online. URL: http://www.espine.com/
diagnosis_lm.html. Downloaded January 10, 2006.
Shamie, Arya Nick, M.D., Saman Aboudi, M.D., Larry
Khoo, M.D., and Jeffrey C. Wang, M.D. “Lumbar
Microdiscectomy Comparing Minimally Invasive
Tubular Retractors versus Standard Retractors,” Paper
No: 185 presented to the American Academy of
Orthopaedic Surgeons (AAOS). Available online. URL:
http://www.aaos.org/wordhtml/anmt2005/ sciprog/
185.htm. Last modified December 29, 2004.
Ullrich, Peter F. Jr., M.D. “Microdiscectomy (Microde-
compression) Spine Surgery,” Spine-health. Available
online. URL: http://www.spine-health.com/topics/
surg/overview/lumbar/lumb03.html. Downloaded
January 30, 2006.
mineral balance Naturally found in the earth,
sea, and sky, minerals are inorganic elements that,
unlike organic matter, can not respond, reproduce
themselves, or get a life. Nevertheless, people need
about 17 essential minerals to survive and thrive.
Those macro minerals include
CALCIUM, MAGNE-
SIUM, PHOSPHORUS, POTASSIUM, silicon, sodium,
and sulfur, while trace minerals include chro-
mium, cobalt, copper, iodine,
IRON, manganese,
moly bdenum, selenium, and
ZINC. Some consider
strontium an essential trace element, too, since it
aids bone growth and prevents tooth decay, but its
abundance in nature means that most people get
enough. Strontium and other semi-essential min-
erals have yet to be adequately studied, but well-
known or not, minerals work to strengthen the
VERTEBRAE, support the BACK and SPINE, maintain
the acid-alkaline balance in the blood, maintain
water balance, assist the production of antibodies,
and aid the movement of
PARASPINAL MUSCLES.
mineral balance 167
Since people and animals cannot consume rocks,
precious metals, or ore, highly cooperative plant
life intervenes. By land, plants sink their roots deep
into the earth and extract minerals from the soil,
sort of like sipping through a straw. Similarly, sea
plants, such as algae, sop up minerals like a sponge
or soak themselves in a salt bath and mineral oils
from the sea. Whether by land or by sea, these
plants provide digestible sources of minerals that
people and animals can safely consume and absorb
into the body. Fresh water taps into a supply of
minerals too, unless distillation or reverse osmosis
processing removes those vital elements.
As absorbable forms of minerals arrive each day,
bones store such essentials as calcium and phospho-
rus in reserve, while protein-produced amino acids
move along whatever minerals the body needs.
Some minerals may be needed more than others, but
trace elements or micro minerals, such as iron, have
laudable functions too. Generally, a body only needs
a trace of trace minerals measured in micrograms,
whereas macro minerals, measured in milligrams,
remain in macrocosmic demand. For example, the
body has a higher need for potassium to put carbo-
hydrates and proteins to good use, while the trace
mineral zinc helps the liver to release
VITAMIN A.
V
ITAMIN C aids iron absorption, and phosphorus aids
the absorption of
VITAMIN B-COMPLEX, while VITA-
MIN D ensures calcium uptake. That same calcium,
so demanded by the bones, also helps the muscles
to contract, whereas another macro-mineral, mag-
nesium, relaxes those muscular contractions. With
the support of other nutrients, minerals smooth the
moves of muscles and bones throughout the body,
but a mineral imbalance does not.
Risks and Complications
E
NVIRONMENTAL INFLUENCES, GENETIC FACTORS, inad-
equate
NUTRITION, various medications, and TEN-
SION put a person at risk for a mineral imbalance.
People with food allergies or those who consume
large quantities of caffeine or alcohol may also be
at higher risk for poor absorption of minerals and
other nutrients too.
In patients with chronic kidney conditions,
poor absorption thins bones, eventually producing
OSTEOPOROSIS. As an article on the National Kidney
Foundation Web site explained, “A change occurs
in the balance between two important minerals in
your body—calcium and phosphorus—leading to
loss of calcium from your bones. . . . When your
kidneys have stopped working normally, phospho-
rus may build up in your blood. Too much phos-
phorus in your blood leads to loss of calcium from
your bones, which weakens them over time.” In
that particular case, a low phosphorus diet, medi-
cation, and supplements of calcium and vitamin D
may help to restore mineral balance.
More commonly, foods receive an overdose of
salt, but excessive sodium can rob bones of cal-
cium. According to an article on a National Insti-
tutes of Health Web site, “sodium (and chloride),
the components of table salt, increase the calcium
requirement by increasing urinary calcium excre-
tion. Individuals with low salt intakes may be able
to maintain calcium balance at low calcium intakes,
while those with more typical U.S. salt intakes will
have higher calcium requirements.”
Statistics and Studies
To identify mineral imbalances, The Trichologi-
cal Society of the United Kingdom studies hair.
According to their Web site, “hair mineral analy-
sis is a screening test, which measures the mineral
content of your hair. Mineral content of the hair
reflects the mineral content of the body’s tissues.
If a mineral deficiency exists in the hair, it usually
indicates a mineral deficiency or excess within the
body.” For example, “the zinc level is high relative
to tissue copper status. A zinc-copper imbalance in
conjunction with low copper levels is a strong indi-
cator of a decrease in the role of copper in many
functions of metabolism. One of the main functions
of copper is its necessity in collagen synthesis. If this
profile becomes both severe and chronic, a decrease
in collagen synthesis can occur. This can then be
an indication to capillary fragility, osteoporosis and
premature greying of the hair.” Hair color as such
does not matter much, but “hair analysis clearly
shows individual deficiencies or excesses as well
as the presence of toxic metals.” Basically, a hair
analysis highlights the nutrients needed.
Special Aids and Adaptations
Some patients experience spinal problems from
having too little mineral resources and others from
168 mineral balance
too much. To complicate matters more, the recom-
mended daily allowance changes according to age
and, sometimes, sex. As a general guideline, Dr.
Elson M. Haas wrote, “All the macrominerals are
needed in doses of over 100 mg. daily, with sodium
requirements somewhere between 2–5 grams,
potassium 3–4 grams, phosphorus about 1–2 grams,
calcium 1–1.5 grams, and magnesium probably
about 0.5–1 gram. The trace minerals are needed in
much smaller amounts. To be on the safe side, daily
intake of iron and zinc should probably be about
15–30 mg.; manganese about 5–10 mg.; and cop-
per about 2 mg. Other trace minerals, such as chro-
mium, selenium, molybdenum, cobalt, and iodine,
are needed in amounts of less than 1 mg. per day.”
If a mineral imbalance seems likely, a physician
can prescribe diagnostic tests to see which essen-
tial elements the body lacks. Then a nutritionist can
design a diet adapted to those very specific needs.
Although nutritional needs may fluctuate from one
person to the next, adaptations can be made for
each individual to stay nicely balanced.
Haas, Elson M., M.D. Staying Healthy with Nutrition. Berke-
ley, Calif.: Celestial Arts Publishing, 1992, 160–161,
186.
Kirschmann, Gayla J. and John D. Kirschmann. Nutri-
tion Almanac, 4th ed. New York: McGraw-Hill, 1996,
29–30.
National Institutes of Health Osteoporosis and Related
Bone Diseases. “Nutrition and the Skeleton: The Role
of Calcium and Other Nutrients,” NIH ORBD. Avail-
able online. URL: http://www.osteo.org/newfile.asp
?doc=r708i&doctitle=Nutrition+and+the+Skeleton
&doctype=HTML+Fact+Sheet. Downloaded February
1, 2006.
National Kidney Foundation. “Bone Disease in Chronic
Kidney Failure.” Available online. URL: http://www.
kidney.org/atoz/atozItem.cfm?id=49. Downloaded Feb-
ruary 1, 2006.
Trichological Society, The. “Hair Mineral Analysis,” U.K.
Available online. URL: http://www.hairscientists.org/
hair-mineral-analysis.htm. Downloaded February 1,
2006.
minimally invasive surgery Not one type of
procedure but many, minimally invasive surgery
invades the body less than traditional methods.
This minimalistic approach also reduces trauma to
surrounding tissue, which can be especially impor-
tant in accelerating recovery after surgery on the
BACK or CERVICAL SPINE.
An article posted by Back.com said, “When talk-
ing about a minimally invasive surgery, you must
consider three factors: scar sizes, muscle dilation
vs. stripping, and recovery time. These three fac-
tors separate a traditional surgery from a minimally
invasive one.” While one type procedure may be
better at times than another, “the biggest differ-
ence between minimally invasive surgeries and
traditional surgeries is that of muscle dilation ver-
sus muscle stripping. Muscle dilation is achieved by
using a series of sequential dilators to separate the
fibers of the muscles in your back, making a small
tunnel, giving the surgeon a view of your spine
through a very small incision. By using these tubes
or channel along with a microscope or endoscope
the surgeon can access the part of your spine where
the problem is, without having to make a long inci-
sion along those spinal levels. When performing a
traditional surgery, the physician makes an incision
along all of the levels of your spine where the prob-
lem lies and ‘strips’ the muscle off of the spine. This
muscle stripping, rather than dilation can often play
a role in how quickly a patient recovers.”
Risks and Complications
As with any
SURGERY, minimally invasive proce-
dures can cause bleeding, infection, or nerve dam-
age. Unlike other surgeries though, the surgeon may
not be able to see the full picture since the scope of
an endoscope, microscope, or other small instru-
ment may limit the view. Also, the skillful use of
active chemicals, laser light, balloons, or other tools
takes a bit of practice. Therefore, inquiring patients
might ask about the experience and success rate a
particular surgeon has.
Statistics and Studies
After reviewing the historical perspectives of
minimally invasive techniques used on the
SPINE,
a group of physicians from Stanford University
discussed their findings in Neurosurgical Focus.
According to their report, “Virtually all aspects of
the spinal axis can be approached and treated in
minimally invasive surgery 169
a minimally invasive approach. . . . With the
innovation of better optics and video equipment,
retractor and instrumentation systems, image
guidance systems, and new biological agents, the
majority of traditional ‘open’ spinal procedures
can now be performed in a minimalistic way.
For most minimally invasive surgical procedures,
however, long-term . . . data are still lacking. In
addition, the use of new technology will require a
new learning curve that may be discomforting for
many surgeons. Special skills may be needed that
are beyond those of traditional open surgery.”
Special Aids and Adaptations
Minimally invasive surgery adapts technology to
surgical techniques. As an article on SpineUniverse
explained, “Endoscopic techniques have been used
for several decades, but these were exclusively for
diagnostic purposes. In the late 1970s and early
1980s, endoscopic techniques were advanced so
that both a diagnosis could be made and the disease
could be treated. These same endoscopic techniques
used in other surgical disciplines have now been
advanced to the treatment of spinal disorders.” For
example, an endoscope may be used during surgery
for
DEGENERATIVE DISC DISEASE, a FRACTURE, HERNI-
ATED DISC, KYPHOSIS, SCOLIOSIS, or SPINAL TUMOR to
“speed recovery, minimize post-operative pain and
improve the final outcome.”
Cleveland Clinic, The. “Minimally Invasive Endoscopic
Spinal Surgery,” SpineUniverse. Available online.
URL: http://www.spineuniverse.com/displayarticle.
php/article2016.html. Last updated June 20, 2005.
Department of Neurological Surgery, University of Pitts-
burgh. “Minimally Invasive Spine Procedures,” Neuro-
logical Spine Services Division. Available online. URL:
http://www.neurosurgery.pitt.edu/spine/minimal/.
Downloaded January 30, 2006.
Medtronic Sofamor Danek. “Minimally Invasive Options,”
Back.com. Available online. URL: http://www.back.
com/articles-minimally_invasive.html?mastbox=yep.
Updated February 17, 2005.
Thongtrangan, Issada, M.D., Hoang Le, M.D., Jon Park,
M.D., and Daniel H. Kim, M.D. “Minimally Invasive
Spinal Surgery: a Historical Perspective,” Neurosurgical
Focus 16, no. 1 (January 2004).
MRI See MAGNETIC RESONANCE IMAGING.
multiple myeloma See MYELOMA BONE DISEASE.
muscle cramp or spasm Involuntarily, mus-
cle contractions tighten the
CERVICAL SPINE, knot
PARASPINAL MUSCLES in the BACK, or cause a body
to twitch. Often,
TENSION cramps neck muscles,
but faulty
POSTURE can too, for instance as a per-
son bends over a book or a workbench. Fatigue,
dehydration, and overuse can send muscles into a
spasm as can a lack of
MINERAL BALANCE. If a muscle
fails to relax, the tightness may tie up the
RANGE OF
MOTION.
Symptoms and Diagnostic Path
Primary symptoms include
ACUTE PAIN, which, in
the
LUMBAR SPINE, may be felt as a BACKACHE or
LOW BACK PAIN. In general, tightly knotted muscles
can be felt anywhere muscles exist, not only by the
pain felt, but by feeling with the fingers and find-
ing a taut area with little give.
ATHLETES and others
can often self-diagnose the problem, especially if
muscle spasms occur after heavy practice or strenu-
ous
EXERCISE.
Treatment Options and Outlook
To treat neck spasms, Dr. Pierre Rouzier advised, “If
your neck spasm has just occurred, put ice packs on
your neck for 20 to 30 minutes three to four times
a day.” After that initial treatment, “sometimes,
especially with recurrent spasms, moist heat can
help. Put warm, moist towels on your neck for 20
minutes, or take hot showers or baths.” In addition,
“you may be able to massage your neck yourself
by finding the tight muscles and putting deep pres-
sure on these muscles. You might also get a mas-
sage from a friend or therapist.” Although
MASSAGE
THERAPY and TRIGGER POINT THERAPY can help most
patients with
NECK PAIN, “neck spasms are a com-
mon physical symptom caused by stress or depres-
sion. Identification of these problems and treatment
of them may help considerably with neck spasms.”
For muscles in general, “spasms are best treated
with stretching exercises.”
170 MRI
To alleviate the pain of spasms, NONSTEROIDAL
ANTI-INFLAMMATORY DRUG (NSAID) THERAPY may
help. If muscle cramps continue, medical attention
should be sought. In severe cases,
MUSCLE RELAX-
ANTS or a SPINAL INJECTION may be needed to relax
the contraction.
Dr. Norman L. Epstein addressed “Benztropine
for Acute Muscle Spasm in the Emergency Depart-
ment.” According to the article, “Many patients
arrive in the emergency department with acute
lumbar and cervical muscle spasm . . . that occurs
either spontaneously or secondary to nonimpact
axial injuries (i.e. lifting and twisting).” For exam-
ple, a patient might present
TORTICOLLIS caused by
twisted
LIFTING or other awkward movement. To
treat these acute spasms in the neck or back, Dr.
Epstein said, “My hypothesis was that benztropine,
an anticholinergic medication, would reverse the
state of muscle spasm and thus provide good pain
relief for these patients.” Of the eight persons who
received that treatment within 24 hours of muscle
spasm, “every patient experienced substantial relief
and improved range of motion.”
Risk Factors and Preventive Measures
In the online article “Muscle Spasms,” Dr. Pierre
Rouzier recommended, “If you tend to get mus-
cle cramps during exercise, make sure you drink
enough fluids. Sports drinks may be very helpful.”
Also, “proper stretching exercises will help prevent
spasms.”
Sometimes muscle cramps occur after
SURGERY.
As Dr. Irwin M. Siegel explained, “Muscle spasm is
usually an effort on the part of the body to splint an
injured area and prolonged spasm can cause pain in
and of itself. Both trauma and interruption of circu-
lation can cause muscle spasm and pain. Sometimes
a ‘vicious cycle’ is set up with pain causing spasm and
spasm causing more pain. If the fusion has been suc-
cessful . . . . , the condition of pain and muscle spasm
can be treated by physical therapy, muscle relaxants
and the use of an appropriate back support.”
In general, however, adequate fresh water, well-
balanced
NUTRITION, and daily ACTIVITY that includes
stretching may prevent future episodes. Warm-ups
prior to exercise should also lessen the risk of mus-
cle cramping.
Epstein, Norman L., M.D. “Benztropine for Acute Muscle
Spasm in the Emergency Department,” Canadian Medi-
cal Association Journal 164, no. 2 (January 23, 2001):
203–204.
Rouzier, Pierre, M.D., McKesson Provider Technologies.
“Muscle Spasms,” University of Michigan Health Sys-
tem. Available online. URL: http://www.med.umich.
edu/1libr/sma/sma_musspasm_sma.htm. Downloaded
February 4, 2006.
———, McKesson Provider Technologies. “Neck Spasms,”
University of Michigan Health System. Available
online. URL: http://www.med.umich.edu/1libr/sma/
sma_neckspsm_sma.htm. Last modified April 29,
2005.
Siegel, Irwin M., M.D. “Muscle Spasm From Lumbar
Fusion,” Muscular Dystrophy Association. Available
online. URL: http://www.mdausa.org/experts/question.
cfm?id=1870. Downloaded February 4, 2006.
muscle relaxants This type of medication cuts
people some slack. Besides releasing
TENSION in the
PARASPINAL MUSCLES of the BACK, a muscle relaxant
eases the stiffness of
SPRAINS, STRAINS, and muscle
spasm. Muscles loosen up. The person loosens up,
and the limber body can then perform therapeutic
EXERCISE with greater ease and interest. Often pre-
scribed at the onset of
LOW BACK PAIN, this group of
drugs provides immediate but temporary treatment
to get a person moving again.
Dosage and Potential Side Effects
Spine-health.com provided information on three
relaxants commonly used: carisoprodol (Soma),
diazepam (Valium), and cyclobenzaprine (Flexeril).
For muscle spasm, 350 mg of carisoprodol may be
taken every eight hours as needed, but not for long
as it can be habit-forming. Diazepam (Valium),
which can also be habit-forming, “is usually limited
to one to two weeks of use, and the typical dos-
age is 5–10 mg every six hours as needed to relieve
low back pain associated with muscle spasm. . . .
Patients should also note that Valium is a depres-
sant and can worsen depression associated with
chronic pain.” If needed, cyclobenzaprine “can
be used on a longer-term basis and actually has a
chemical structure related to some antidepressant
muscle relaxants 171
medications, although it is not an antidepressant.
Usually it is prescribed as 10 mg every six hours
as needed to relieve low back pain associated with
muscle spasm, or it can also be prescribed as 10 mg
at night as needed to help with difficulty sleeping.”
Cyclobenzaprine, however, “can impair mental and
physical function.”
Besides the side effects unique to each medica-
tion and each individual, muscle relaxants should
not be taken with alcohol or certain types of medi-
cations. The potential for adverse effects increases
in patients with allergies to foods or drugs, pregnant
or lactating women, young
CHILDREN, ELDERLY per-
sons, and patients with chronic medical conditions,
such as kidney, liver, or psychiatric disorders.
An article posted by MedlinePlus explained,
“Skeletal muscle relaxants act in the central ner-
vous system (CNS) to produce their muscle relaxant
effects. Their actions in the CNS may also produce
some of their side effects. . . . Skeletal muscle relax-
ants may cause blurred vision or clumsiness or
unsteadiness in some people. They may also cause
some people to feel drowsy, dizzy, lightheaded,
faint, or less alert than they are normally. Make sure
you know how you react to this medicine before you drive,
use machines, or do anything else that could be dangerous
if you are dizzy or are not alert, well-coordinated, and
able to see well.”
Statistics and Studies
A group of researchers from Finland reported
their concerns about interactions between mus-
cle relaxants and antidepressants. According to
the article published in the Chemist & Druggist, the
anti-depressant “Faverin (fluvoxamine) dramati-
cally increases the blood concentration of Zanaflex
(tizanidine),” a muscle relaxant, by an average of
33 times. “This can result in a severe and prolonged
fall in blood pressure and enhanced CNS effects.”
Instead of mixing medications, researchers from
Rutgers University School of Pharmacy split them.
Some patients had been advised to divide generic 10
mg tablets in half to get the 5 mg dosage prescribed,
so the researchers decided to try this themselves.
As Drug Topics reported, “Using a tablet splitter and
kitchen knives commonly used by patients, three
researchers each split 30 tablets, which are not
scored, and then weighed the fragments on a spe-
cial scale.” Instead of getting a 5 mg dosage, how-
ever, the hand-carved tablets offered, “anywhere
from 50% to 150% of the dose prescribed.”
Micromedex, Inc. “Drug Information: Skeletal Muscle
Relaxants (Systemic),” MedlinePlus, National Institutes
of Health. Available online. URL: http://www.nlm.nih.
gov/medlineplus/print/druginfo/uspdi/202523.html.
Downloaded January 30, 2006.
Rutgers University School of Pharmacy. “Drug Content
of Split Tablets Varies,” Drug Topics 148, no. 11 (June
7, 2004): 12.
Spine-health.com. “Muscle Relaxants.” Available on-
line. URL: http://www.spine-health.com/topics/conserv/
overview/med/med04.html. Downloaded Jan uary
30, 2006.
Staff. “Drug Interaction Concern,” Chemist & Druggist
(April 10, 2004): 6.
muscle spasm See MUSCLE CRAMP OR SPASM.
muscular dystrophy (MD) Usually brought on
by
GENETIC FACTORS, this group of diseases produces
weakness in the skeletal muscles of
CHILDREN, pri-
marily boys. As MD progresses, atrophy affects the
PARASPINAL MUSCLES, damages POSTURE, and makes
daily
ACTIVITY or routines increasingly difficult to
perform. Eventually, mobility ceases with the qual-
ity of life and, ultimately, the life span severely lim-
ited.
Symptoms and Diagnostic Path
In discussing the most common form of MD known
as Duchenne’s muscular dystrophy, information
from Cedars-Sinai said, “It generally appears from
age three to six years and worsens rapidly. At first,
muscle weakness and wasting (atrophy) within
the pelvic (hipbone) area occurs followed by simi-
lar problems in the shoulder muscles. Eventually,
muscle weakness and atrophy affect the trunk and
forearms and gradually spread to the major muscles
of the body. From 20 to 30 boys of every 100,000
born are affected by Duchenne’s muscular dys-
trophy.” Characteristically, symptoms include, “a
waddling way of walking, difficulty climbing stairs
or rising from sitting and repeated falling. As the
172 muscle spasm
disease worsens, other abnormalities may develop,
such as curvature of the spine.”
Noting similar symptoms, MedlinePlus discussed
another type of MD, “Becker’s Muscular Dystro-
phy.” As that online article explained, “the pat-
tern of symptom development resembles that of
Duchenne’s muscular dystrophy, but with a much
slower rate of progression. Muscle wasting begins
in the legs and pelvis, then progresses to the mus-
cles of the shoulders and neck, followed by loss of
arm muscles and respiratory muscles. Calf muscle
enlargement (pseudohypertrophy) is quite obvi-
ous.” Regarding onset, “symptoms usually appear
in men at about age 12, but may sometimes begin
later. The average age of becoming unable to walk
is 25–30.”
Besides a family history, medical history, and
physical examination, various tests help to confirm
the diagnosis. For example, a physician may request
a blood test and a muscle biopsy. Usually, an
ELEC-
TROMYOGRAM and a NERVE CONDUCTION STUDY will
also be prescribed.
Treatment Options and Outlook
Although no cure exists,
RESEARCH currently
involves options in gene therapy. Meanwhile,
physical therapy and therapeutic
EXERCISE may ease
muscle contractions and minimize
CHRONIC PAIN. To
manage postural problems, a back brace or other
ORTHOTIC device may be prescribed to treat KYPHO-
SIS, LORDOSIS, and SCOLIOSIS. SURGERY may also be
needed to minimize damage to the
SPINE.
Generally, treatments include
STEROID THERAPY.
To discuss this option, Dr. Gregory T. Carter com-
pared two steroids in a question-and-answer column
for the Muscular Dystrophy Association (MDA). As
reported, “of all of the therapeutic classes of drugs
studied in Duchenne muscular dystrophy (DMD),
only the corticosteroids, and in particular pred-
nisone and deflazacort, appear to provide, albeit
temporary, functional improvement for boys with
DMD.” However, “based on the available evidence,
both prednisone and deflazacort have benefit (and
risk). I think the incidence of side effects with pred-
nisone, including weight gain, can be significantly
lowered by using pulse therapy (10 days on/10
days off). This essentially reduces the side effects
to that of deflazacort. Whether deflazacort actually
works better is a question that cannot be succinctly
answered based on the studies that have been done
to date.”
A study from the University of Toronto, Canada,
focused on
ALENDRONATE as a treatment for the
bone-thinning side effects of steroid treatments in
boys whose
BONE MINERAL DENSITY TESTS scored less
than -1.00. As reported in the Archives of Physical
Medicine and Rehabilitation, “improvement in total
body and spine z scores was associated with younger
age at baseline.” Specifically, “in deflazacort-treated
boys, alendronate had a positive effect on BMD z
scores; the effect was greatest when given early in
the course of disease.”
Risk Factors and Preventive Measures
Information from the Loyola University Health Sys-
tem explained, “Muscular dystrophy is a progres-
sive condition that needs life-long management to
prevent deformity and complications. Walking and
sitting often becomes more difficult as the child
grows. Usually by the age of 12, the child needs a
wheelchair because the leg muscles are too weak
to work.”
In addition, inactivity and steroid treatments
commonly cause weight gain and deteriorating
health. For example, MD patients often experi-
ence the adverse effects of too much
WEIGHT. While
NUTRITION does not cure MD, an individualized diet
may help to maintain
MINERAL BALANCE and keep
body weight within the optimal range for that par-
ticular child.
In an overview of preventive measures, the
MDA Web site posted “Facts About Duchenne and
Becker Muscular Dystrophies (DMD and BMD).”
As the article stated, “The impact of DMD and
BMD can be minimized significantly by keeping the
body as flexible, upright and mobile as possible.”
For example,
RANGE OF MOTION exercises can “delay
contractures by keeping tendons from shorten-
ing prematurely.” However, “it’s important that a
physical therapist show you how to do range-of-
motion exercises correctly. . . . By using all avail-
able therapies, patients can prolong their comfort,
function and life expectancy.”
American Accreditation HealthCare Commission, A.D.A.M.
“Becker’s Muscular Dystrophy,” MedlinePlus. Available
muscular dystrophy 173
online. URL: http://www.nlm.nih.gov/medlineplus/
ency/article/000706.htm. Last updated January 6,
2006.
Carter, Gregory T., M.D. “Prednisone or Deflazacort,”
Ask the Experts, Muscular Dystrophy Association,
MDA. Available online. URL: http://www.mdausa.
org/experts/question.cfm?id=3050. Downloaded Feb-
ruary 6, 2006.
Cedars-Sinai Health System. “Muscular Dystrophy.” Avail-
able online. URL: http://www.cedars-sinai.edu/3006.
html. Downloaded February 1, 2006.
Hawker, G. A., R. Ridout, V. A. Harris, C. C. Chase, L. J.
Fielding, and W. D. Bigger. “Alendronate in the Treat-
ment of Low Bone Mass in Steroid-treated Boys with
Duchenne’s Muscular Dystrophy,” Archives of Physical
Medicine and Rehabilitation 86, no. 2 (February 2005):
284–291.
Loyola University Health System. “Muscular Dystrophy.”
Available online. URL: http://www.luhs.org/health/
topics/nervous/muscular.htm. Last updated January
5, 2005.
Muscular Dystrophy Association. “Facts About Duchenne
and Becker Muscular Dystrophies (DMD and BMD),”
MDA. Available online. URL: http://www.mdausa.
org/publications/fa-dmdbmd-treat.html. Downloaded
February 6, 2006.
musculoskeletal disorders In the musculoskel-
etal system, individual mechanisms of the
BACK and
SPINE include PARASPINAL MUSCLES, spinal nerves,
VERTEBRAE, DISCS, joints, and connective ligaments
and tendons. Each of these aspects must work
well, or inflammation,
ACUTE PAIN, CHRONIC PAIN,
muscle spasm, or
NERVE COMPRESSION may result.
For example, a
BACK INJURY, FLEXION-EXTENSION
INJURY, RIB INJURY, or other type of SPINAL INJURY,
including overuse, can rearrange musculoskeletal
components, making the mechanisms downright
disorderly. Similarly,
SPINAL INFECTIONS can cause
temporary disorder, whereas progressive conditions,
such as
ARTHRITIS, JUVENILE RHEUMATOID ARTHRITIS,
MUSCULAR DYSTROPHY, and OSTEOPOROSIS, can subtly
disrupt body mechanics throughout the musculo-
skeletal system.
According to the American College of Rheuma-
tology (ACR), “approximately 1 of 7 patient visits
to a primary care provider is prompted by muscu-
loskeletal pain or dysfunction. While many or even
most patients with these symptoms have benign,
self-limited conditions, arthritis and chronic mus-
culoskeletal disorders are leading causes of disability
and work absenteeism, and are occasionally life-
threatening. Determining whether the symptom
is from local injury or inflammation, a mechanical
problem, or a systemic illness will direct subsequent
evaluation and management.” For example, “mus-
culoskeletal emergencies may present with acute
symptoms,” whereas “patients with systemic rheu-
matic diseases, such as rheumatoid arthritis . . . ,
may have prolonged morning stiffness in multiple
symptomatic joints, less stiffness after using their
joints, and may have constitutional symptoms
(malaise, fever, weight loss) or signs or symptoms
of multi-system involvement.” Conversely, “indi-
viduals with local mechanical problems,” such as
a muscle
SPRAIN or STRAIN, “and osteoarthritis (OA)
typically have little morning stiffness, only one or
a few symptomatic areas, no pain at rest, wors-
ened symptoms with or after sustained activity,
and no symptoms or signs of a systemic illness.”
The ACR also devised a diagnostic questionnaire
for professional assessment, but before seeing a
rheumatologist or other doctor, patients might ask
such questions of themselves. For instance, “What
is hard to do now that you could do before, and
how does this affect your daily life?” The answers
can help to clarify the symptoms, narrow down
the appropriate diagnostic tests, and offer potential
solutions too.
Symptoms and Diagnostic Path
During a physical examination, the doctor will
attempt to discern whether the source of pain or
inflammation arises from a bone, muscle, disc, joint,
spinal nerve, or underlying medical condition. Ini-
tially, this may be done by testing
RANGE OF MOTION
during an office visit. Later, outpatient tests, such
as X-
RAYS or MAGNETIC RESONANCE IMAGING, may be
needed to locate or assess damage. In some cases,
BONE MINERAL DENSITY TESTS, ELECTROMYOGRAM, or
NERVE CONDUCTION STUDY may be recommended.
If a patient presents muscle weakness, atrophy,
or other symptom of a systemic illness, appropri-
ate tests may then include a blood test, urinalysis,
biopsy, or
BONE SCAN. As the ACR stated, “The most
174 musculoskeletal disorders
useful information in evaluating musculoskeletal
pain comes from the history and physical exami-
nation, with reassessment as necessary. When the
diagnosis and proper management are obscure,
selective ordering of tests and/or consultation may
be the most cost-effective approach.”
Treatment Options and Outlook
Both the therapy and the outlook depend on the
condition. For instance, a
FRACTURE that occurred
when a child fell from a tree limb will usually have
a better outcome than a
VERTEBRAL COMPRESSION
FRACTURE arising when an ELDERLY patient simply
got out of bed. Both conditions might require a cast
or
ORTHOTIC device. Both might require SURGERY.
Both might involve therapeutic
EXERCISE or better
forms of
NUTRITION. However, the compression frac-
ture would likely necessitate long-term use of med-
ication, such as
BISPHOSPHONATES, to slow bone loss.
For another example,
CHILDREN with progressively
weakening muscles may have far different treat-
ment and a more somber outlook than
ATHLETES
who overexert muscles during game practice.
Risk Factors and Preventive Measures
The immediate medical history of a patient not only
offers clues for diagnosing a musculoskeletal disorder
but provides information about ongoing risks and pre-
ventives. In assessing the most common disorders, a
fact sheet from the National Institute for Occupational
Safety and Health (NIOSH) included information
from the Bureau of Labor Statistics (BLS) on “Work-
Related Musculoskeletal Disorders.” According to the
NIOSH, “musculoskeletal disorders of any cause are
among the most prevalent medical problems, affect-
ing 7% of the population and accounting for 14%
of physician visits and 19% of hospital stays.” Fur-
thermore, “when looking specifically at cases involv-
ing days away from work, . . . approximately 32%
or 705,800 cases were the result of overexertion or
repetitive motion. This figure includes back injuries.”
For most types of musculoskeletal disorders,
ERGO-
NOMIC FACTORS and proper means of LIFTING can often
be addressed to prevent recurrence.
A satisfying job may prevent problems too. In
an overview of musculoskeletal disorders (MSDs)
posted by the NIOSH, Dr. Bruce P. Bernard said,
“There is increasing evidence that psychosocial fac-
tors related to the job and work environment play
a role in the development of work-related MSDs of
the upper extremity and back. Though the findings
of the studies reviewed are not entirely consistent,
they suggest that perceptions of intensified work-
load, monotonous work, limited job control, low job
clarity, and low social support are associated with
various work-related MSDs. As some of these factors
are seemingly unrelated to physical demands, and
a number of studies have found associations even
after adjusting for physical demands, the effects of
these factors on MSDs may be, in part or entirely,
independent of physical factors.” In such cases, a job
change may help some patients to find a more fitting
way to employ their musculoskeletal systems.
American College of Rheumatology Ad Hoc Commit-
tee on Clinical Guidelines. “Guidelines for the Initial
Evaluation of the Adult Patient with Acute Muscu-
loskeletal Symptoms,” Arthritis & Rheumatism, Official
Journal of the American College of Rheumatology 39, no. 1
(January 1996): 1–8.
Bernard, Bruce P., M.D., editor. “Chapter 7. Work-Related
Musculoskeletal Disorders and Psychosocial Factors,”
The National Institute for Occupational Safety and
Health (NIOSH). Available online. URL: http://www.
cdc.gov/niosh/ergtxt7.html. Downloaded February 7,
2006.
National Institute for Occupational Safety and Health, The.
“Work-Related Musculoskeletal Disorders,” NIOSH
Facts. Available online. URL: http://www.cdc.gov/niosh/
muskdsfs.html. Downloaded February 7, 2006.
myalgia See PAIN.
myelogram, myelography More invasive yet
sometimes clearer than
MAGNETIC RESONANCE IMAG-
ING, this diagnostic test uses X-RAYS to show con-
ditions in the
SPINE, SPINAL CORD, and surrounding
area. If a doctor needs additional information, a
COMPUTED TOMOGRAPHY (CT) SCAN may be per-
formed at the same time.
Procedure
A person must stop eating about eight hours before
a myelogram but continue to drink more fluids than
myelogram, myelography 175
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