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and symptoms of osteoarthritis and rheumatoid
arthritis.”
In 2005, FDA Consumer Magazine said, “The FDA
is asking the manufacturers of all non-prescrip-
tion NSAIDs sold over the counter (OTC) to revise
their labels to include more specific information
about potential cardiovascular and gastrointestinal
risks and information on the safe use of the drugs.
The agency also is asking manufacturers of OTC
NSAIDs to include a warning about potential skin
reactions.”
Statistics and Studies
According to a study reported in Inflammopharmacol-
ogy, “population studies and World Health Organi-
sation (WHO) statistics indicate that 10–50% of
individuals suffer from musculoskeletal disorders.
Up to 3% will be classified as disabled due to their
bone and joint condition, and the majority will suf-
fer from pain. Almost all will require non-steroidal
anti-inflammatory drugs (NSAIDs) and other anal-
gesics for their management. The large majority of
this population is elderly and, hence, at greater risk
of adverse effects to the NSAIDs. The NSAIDs are a
necessary choice in pain management because of
the integrated role of the cyclo-oxygenase (COX)
pathway in the generation of inflammation and in
the biochemical recognition of pain. For over 80
years the management of musculoskeletal pain was
hampered by NSAID toxicity problems related to
the traditional NSAIDs.” However, “recent studies
have shown that the use of a . . . drug with tra-
ditional NSAIDs and with COX-2-selective inhibi-
tors has been shown to significantly reduce GI
symptoms. . . . Thus, the traditional NSAIDs have
been re-established as the preferred choice in the
management of arthritis and musculoskeletal
disorders.”
Besides easing the
CHRONIC PAIN of ARTHRITIS or
MUSCULOSKELETAL DISORDERS, NSAIDs alleviate pain
in
CANCER patients. According to JAMA, The Journal
of the American Medical Association, “some nonste-
roidal anti-inflammatory drugs (NSAIDs) are fac-
ing controversy due to their link to increased risk
of myocardial infarction and stroke. However, a
new study found that long-term daily NSAID use
reduced the risk of oral cancer in some smokers but
did not increase overall survival thus suggesting
that the value of some of these drugs for certain
cancer patients might outweigh the risks.”
Special Aids and Adaptations
Patients aid the effectiveness of an NSAID and
avoid most of its side effects by having a little food
and lots of water with the dosage recommended
on the label. Sometimes, a doctor may recommend
a higher dose to be used as a
PAIN RELIEVER. If an
NSAID, such as aspirin, is used to prevent blood
clots, however, less is usually more effective as a
maintenance dosage since a minimal dose does the
job with minimal risk.
American Academy of Orthopaedic Surgeons. “What
Are NSAIDs?” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=
398&topcategory=General%20Information. Down-
loaded February 15, 2006.
FDA Consumer Magazine. “FDA Announces Changes
Affecting the Marketing of Non-Steroidal Anti-Inflam-
matory Drugs,” May–June 2005 issue, U.S. Food and
Drug Administration. Available online. URL: http://
www.fda.gov/fdac/features/2005/305_nsaid.html.
Downloaded February 15, 2006.
FDA Talk Paper. December 23, 2004. “FDA Issues Public
Health Advisory Recommending Limited Use of Cox-
2 Inhibitors,” U.S. Food and Drug Administration.
Available online. URL: http://www.fda.gov/bbs/topics/
ANSWERS/2004/ANS01336.html. Downloaded Febru-
ary 15, 2006.
Hampton, Tracy. “NSAID Studies Abound in Cancer
Research: Drugs May Have Niche in Prevention and
Treatment.: (Nonsteroidal Anti-inflammatory Drugs),”
JAMA, The Journal of the American Medical Association
293, no. 21 (June 1, 2005): 2,579–2,580.
Kean, Walter F. “The Use of NSAIDs in Rheumatic Disor-
ders 2005: a Global Perspective,” Inflammopharmacol-
ogy 13, no. 4 (2005): 343–370.
nutrition Daily nutrition consists of an alphabet of
vitamins with trace minerals, such as
IRON and ZINC,
and essential minerals, such as
CALCIUM, MAGNESIUM,
PHOSPHORUS, and POTASSIUM, best kept in MINERAL
BALANCE. Nutrition also provides life-sustaining pro-
teins, fats, and carbohydrates for
BONE BUILDING the
BACK and SPINE, energizing cells, overcoming TEN-
186 nutrition
SION, combating illness, and repairing hard matter
or soft tissue throughout the body.
Diets may be debated, and nutritional needs may
be complex, but essentially, nourishment flourishes
in simplicity. Basically, the closer a food remains
to its natural state, the more nutritious and bone-
nurturing it will be. With little or no food process-
ing to strip away nutrients and fiber, natural foods
provide the most wholesome source of vitamins,
minerals, and trace elements, many of which have
not yet been fully studied. Fresh foods also grow
naturally free of food colorings, preservatives, and
other potentially harmful additives.
As another basic guideline, well-balanced nutri-
tion almost always occurs when a variety of foods
has been selected for the week. Typically, those
diverse tastes, textures, and colors can be found
on the outside walls of a grocery store. Except for
grains, which rarely require refrigeration, outer
store aisles highlight the basic food groups in col-
orful displays of fresh fruit, fresh vegetables, dairy
products, eggs, fish, and meat. Perhaps weekly, one
might encircle the store, aiming for the ultimate
goal: Bin there, ate that.
Optimal menu choices will not, of course, be
the same for everyone.
INFANTS, young CHILDREN,
and
ELDERLY persons require foods that can eas-
ily be digested, whereas active
ADOLESCENTS and
young to middle-aged adults may need somewhat
meatier fare. Temporarily, pregnant women and
nursing mothers may need to add an all-natural
nutritional supplement to their healthy diets. How-
ever, patients with
METABOLIC BONE DISEASE or MET-
ABOLIC DISEASES OF MUSCLE do not readily absorb
nutrients so may need to continue supplements,
depending on the advice of their physicians. Also,
people with bone loss caused by
EATING DISORDERS
or bone problems caused by the adverse effects of
WEIGHT have special dietary needs that must be met
to restore balance. In addition,
GENETIC FACTORS and
ENVIRONMENTAL INFLUENCES alter the specific needs
for a nutrient. For example, a person may require
more
VITAMIN A, VITAMIN C, and VITAMIN E than
commonly needed to boost the immune system. As
a memory device, those same three vitamins com-
bine to combat or A. C. E. an illness.
To nourish the back and spine and strengthen
bones in general, nutritionists agree on the impor-
tance of calcium and
VITAMIN D. However, an
editorial in the QJM: An International Journal of
Medicine posed the question, “Nutrition and bone:
is there more to it than just calcium and vitamin
D?” As the editorial noted, “It is feasible . . . that
supplementation of other macro- or micronutri-
ents may have value in influencing fracture risk,
perhaps especially in those with specific genetic
traits. . . . Of even more practical significance
would be the opportunity to relate specific food
groups to our risk of future fracture, giving a real
opportunity for targeted nutritional advice.” For
example, “potassium is worthy of attention due
to its role as a buffer for . . . acid production. . . .
Potassium bicarbonate ingestion reduces urinary
calcium excretion and improves calcium balance
in healthy young adults and can both reduce
bone resorption and increase formation in post-
menopausal women.” Conversely, “an increase
in dietary sodium intake leads to an increase in
urinary sodium and a consequent increase in uri-
nary calcium loss.” Furthermore, “dietary calcium:
phosphate ratio may have importance. . . . If this
is the case, the habitual consumption of carbon-
ated drinks with their low calcium: phosphate
ratio may have detrimental effects which have yet
to be fully elucidated.”
As the editorial added, “the vitamin-K-dependent
proteins . . . are important constituents of bone. . . .
Recent evidence has suggested that low intakes of
vitamin K are associated with hip fracture in both
women and men.” Since
VITAMIN K counteracts
blood-thinners, patients need to amend their menus
carefully to avoid foods high in that vitamin. For
those who do not need to be wary of eggplant or
other sources of K, the editorial suggested, “Rather
than focus on individual nutrients, an alternative
way of investigating the effect of diet on disease is
to study food patterns and food groups. Recently it
has been suggested that a diet rich in fruits and veg-
etables may be associated with higher bone mass,
although other food groups have not been exam-
ined. Dietary patterns could exert their influence
through the nutrients contained in the foods (i.e.,
vitamins, minerals) or through other components.”
Gardeners can check out some components
at a local agricultural center or county extension
agency, but the presence of
PHYTOCHEMICALS, such
nutrition 187
as antioxidants and PHYTOESTROGENS, may be diffi-
cult to ascertain. However, to check out the acid-
alkaline balance in the body, most people can do
this themselves at home by checking their saliva
with litmus paper purchased from a pharmacy. The
information can then be used to reassess the diet.
For example, if the litmus paper shows high acid-
ity, the person may need to limit the consumption
of meat, dairy products, wheat products, and sug-
ars, planning instead a menu of fruits, vegetables,
oat products, and wild rice. To replace acid-forming
drinks, such as coffee, tea, and colas, a choice glass
of filtered water with a squeeze of lime or lemon
may help to re-establish a healthy acid-alkaline bal-
ance. That particular drink adds active enzymes to
the diet too, thus aiding digestion. Fresh fruits and
vegetables also bring enzymatic action and health-
ful phytochemicals to the dinner table unless, of
course, preservatives have been added, thus killing
the active nutrients. However, a healthier choice of
preservative-free dressings can usually be found in
a refrigerated case on the outer aisle of a grocery
store.
Up and down the aisles and ages, nutrition con-
tinues to play a major role in a healthy lifestyle. For
example, the article “Nutrition and Aging—Prac-
tical Advice for Healthy Eating” in the Journal of
the American Medical Women’s Association said, “The
2005 Dietary Guidelines for Americans emphasize
healthy weight: physical activity: choosing a variety
of grains, especially whole-grain foods, fruits, and
vegetables daily: a diet low in saturated fat, cho-
lesterol, total fat, added sugars, and sodium: and
moderate alcohol intake for those who drink.” For
most age groups, “fruits and vegetables are associ-
ated with prevention of major chronic diseases.”
Furthermore, “new research suggests that fruits
and vegetables may protect bone health as well.”
Risks and Complications
Eating the most natural foods sounds uncompli-
cated and risk-free, but that natural state makes
them apt to acquire surface bacteria. Like other
external contaminants, however, bacteria can usu-
ally be washed away with a solution of three parts
water and one part vinegar. Vinegar-water can also
be used to wipe countertops to avoid contamina-
tion during preparation time at home. For natural
foods such as grains and ground beef that cannot be
surface-washed, thorough cooking eradicates most
contaminants.
Besides their concern for food safety, the U.S.
Food and Drug Administration (FDA) warned,
“approximately 2 percent of adults and about 5
percent of infants and young children in the United
States suffer from food allergies.” Furthermore,
“each year, roughly 30,000 individuals require
emergency room treatment and 150 individuals die
because of allergic reactions to food.” With “eight
major foods or food groups—milk, eggs, fish, . . .
shellfish, tree nuts, peanuts, wheat, and soybeans”
accounting for “90 percent of food allergies,” the
FDA now requires clear labeling of products con-
taining those ingredients.
While timely emergency treatment may offset
a severe allergic response, no cure exists for food
allergies. Therefore, infants and young children
should be introduced to no more than one new
food each week, starting with a mere spoonful.
Food-sensitive adults and adolescents must not
only avoid foods and ingredients known to produce
an adverse reaction, they should make companions
and others aware, especially when dining out. At a
restaurant, for example, a person who is allergic to
peanuts might ask about the ingredients in a salad
or dessert but also find out if peanut oil will be used
in cooking.
Inquiring minds want to know what they are
eating, for safety’s sake and also for the overall
nutritional content. The FDA helps to satisfy those
answers by insisting on product labeling, but food
packaging labels do not mention everything of
value nor of a potential risk. For example, some
dietary supplements, such as calcium, have been
proven to aid
OSTEOPOROSIS and other conditions
involving bone loss, but that does not make calcium
tablets the best choice for healthy individuals inter-
ested in bone building. H
ERBAL THERAPY and other
supplements, such as
GLUCOSAMINE, appear to ben-
efit patients with
OSTEOARTHRITIS, but all of the evi-
dence is not yet in. Also, all health supplements are
not created equal, which means that some follow
higher standards and maintain a stronger potency
than others.
Discussing such issues in The Mount Sinai Jour-
nal of Medicine, Dr. Jeffrey I. Mechanick said, “Cre-
188 nutrition
ative solutions to clinical problems incorporate . . .
qualities that cannot always be scientifically tested.
However, the advocacy of unproven therapies,
heralded as standards of care or appropriate inter-
ventions, cannot be condoned. Such is the case
for many of the published indications for dietary
supplements . . . and their seemingly widespread
recommendation for a host of ailments.” When
possible, then, one might do well to buy products
only from the most reputable companies while con-
tinuing to stalk those outer grocery aisles.
Statistics and Studies
Apparently, the majority of teenagers favor the cen-
ter of the grocery store. According to the National
Center for Chronic Disease Prevention and Health
Promotion, only 22 percent of the high school stu-
dents surveyed in 2003 had five or more servings
of fruits and vegetables each day. That same year,
slightly more than 11 percent of the girls and 22
percent of the boys drank three or more glasses
of milk a day. Over 81 percent of teens, however,
drank a glass of fruit juice, and over 83 percent ate
at least one vegetable.
Regarding adults, a group of researchers from
the University of Aberdeen in the United King-
dom (U.K.) studied the typical Western diet then
reported, “Low Dietary Potassium Intakes and
High Dietary Estimates of . . . Acid Production
Are Associated with Low Bone Mineral Density
in Premenopausal Women and Increased Markers
of Bone Resorption in Postmenopausal Women.”
That title, which is itself a mouthful, says a lot
about the acid-alkaline balance mentioned earlier.
As an abstract of the study stated, “The Western
diet may be a risk factor for osteoporosis. Excess
acid generated from high protein intakes increases
calcium excretion and bone resorption. Fruit and
vegetable intake could balance this excess acidity
by providing alkaline salts of potassium,” since that
base neutralizes the acid. Thus, the U.K. research-
ers concluded, “Dietary potassium . . . may exert a
modest influence on markers of bone health, which
over a lifetime may contribute to a decreased risk
of osteoporosis.”
In the United States, a group of researchers from
Tufts’ Jean Mayer USDA Human Nutrition Research
Center on Aging investigated “Vitamin B12 Linked
to Bone Health vs. Osteoporosis.” According to
the article by that name in the university publica-
tion, Health & Nutrition Letter, “Vitamin B12, found
in dairy products, meats, poultry and fish as well
as in many fortified cereals, may be an important
weapon in your battle against osteoporosis.” With
more than 2,500 men and women participating
in the Framingham Osteoporosis Study at Tufts,
researchers “found that both men and women with
low vitamin B12 levels also averaged lower bone
mineral densities than those with higher levels.” To
be more specific, “the men with low vitamin Bl2
levels had significantly lower bone density in sev-
eral areas of the hip, and the women low in B12
had particularly low bone density in the spine.”
Special Aids and Adaptations
Patients who do not absorb vitamins well from food
sources may need the help of all-natural supple-
ments, in which case a
VITAMIN B-COMPLEX will
keep B12 in balance with others in the B family.
For people with high acidity, fortified cereals higher
in oats or other alkaline-producing grains offer a
tasty option and provide the daily requirement for
other known nutrients. For people with sensitivi-
ties to dairy products, soy milk may make cereal
more palatable. However, regular milk on fortified
cereal offers a reasonably nutritious breakfast or a
healthy evening snack with calcium to assist
SLEEP.
Good grains can begin a good morning too. At
any time of day or night, food choices can be adapted
to fit the present person and the present need. For
example, after an illness or tiring
EXERCISE, people
usually need fresh fruits to help detoxify the body.
Later in the day, protein helps to rebuild cells. If
energy lags mid-day, fresh fruit provides the carbo-
hydrates needed for energy. If hair, skin, or nails
feel dry and lifeless, chances are, the bones echo the
feeling. In that case, a person might adapt by adding
an additional spoon or two of vegetable fat, such as
canola or olive oil, each day to lubricate achy joints
and transport hormones throughout the body.
Each person differs, yet most people need a
variety of foods to assure well-balanced nutrition.
Variety also spices life. As an offbeat rule, however,
people should be as wary as a finicky toddler when-
ever food colors clash on a plate. For example, slices
of red tomatoes look unappetizing next to a blob of
nutrition 189
sweet potatoes, but if eaten together, they might
taste worse than they look. Conversely, someone
who favors only white foods will most likely lack
nutrients such as vitamin A or C. However, sci-
entific studies of this artistic interplay of nutrients
have yet to be fully performed.
Healthy Youth! “Youth Online: Comprehensive Results,”
National Center for Chronic Disease Prevention and
Health Promotion, CDC. Available online. URL: http://
apps.nccd.cdc.gov/yrbss/CategoryQuestions.asp?Cat=
5&desc=Dietary%20Behaviors. Last updated Septem-
ber 8, 2004.
Johnson, Mary Ann. “Nutrition and Aging—Practical
Advice for Healthy Eating,” Journal of the American
Medical Women’s Association 59, no. 4 (2005): 262–269.
Macdonald, H. M., S. A. New, W. D. Fraser, M. K. Camp-
bell, and D. M. Reid. “Low Dietary Potassium Intakes
and High Dietary Estimates of Net Endogenous Acid
Production Are Associated with Low Bone Mineral
Density in Premenopausal Women and Increased
Markers of Bone Resorption in Postmenopausal
Women,” American Journal of Clinical Nutrition 81, no.
4 (April 2005): 923–933.
Mechanick, Jeffrey I., M.D. “The Rational Use of Dietary
Supplements and Nutraceuticals in Clinical Medicine,”
The Mount Sinai Journal of Medicine 72, no. 3 (May
2005): 161–165.
Reid, D. M., and H. M. Macdonald. “Nutrition and Bone:
Is There More to It than Just Calcium and Vitamin
D?” QJM: An International Journal of Medicine 94, no. 2
(2001): 53–56.
Staff. “Vitamin B12 Linked to Bone Health vs. Osteoporo-
sis,” Tufts University Health & Nutrition Letter 23, no. 4
(June 2005): 1–2.
U.S. Food and Drug Administration. “Food Allergen
Labeling and Consumer Protection Act of 2004 (Title II
of Public Law 108–282),” FDA. Available online. URL:
http://www.cfsan.fda.gov/~dms/alrgact.html. Down-
loaded February 18, 2006.
190 nutrition
191
obesity
See WEIGHT, EFFECTS OF.
opiates, opioids for pain Derived from the opium
extracted from poppy, an opiate contains such alka-
loids as morphine, codeine, and heroine. Besides
this natural source, synthetically produced opioids
also provide a narcotic form of
PAIN MANAGEMENT.
Unlike other
PAIN RELIEVERS, though, doctors often
hesitate to prescribe these powerful drugs since
patients can become addicted to them.
Addressing this concern, an article in JAOA, The
Journal of the American Osteopathic Association, said,
“Administration of opioids for pain control has been
shown to be an effective way to improve pain con-
trol and quality of life.” However, “initial therapy
should be with the lowest effective dose possible
to minimize pain and medication side effects and
to maximize the quality of life.” Then, “follow-up
visits and continued monitoring is crucial for suc-
cess and proper management of pain. These visits
ensure constant communication, patient coordina-
tion, patient support, and opportunities for educa-
tion and proper adjustments to medication. Visits
should be scheduled every 2 weeks for the first 2
to 4 months, then once a month.” As the JAOA
article also pointed out, “understanding the differ-
ence between addiction (psychological and deviant
behavioral condition) and physical dependence . . .
should improve physician comfort levels in pre-
scribing opioid therapy.”
InfoFacts from the National Institute on Drug
Abuse further explained, “Long-term use also can
lead to physical dependence—the body adapts to
the presence of the substance and withdrawal symp-
toms occur if use is reduced abruptly. This can also
include tolerance, which means that higher doses
of a medication must be taken to obtain the same
initial effects. Note that physical dependence is not
the same as addiction—physical dependence can
occur even with appropriate long-term use of opi-
oid and other medications,” whereas “addiction . . .
is defined as compulsive, often uncontrollable drug
use in spite of negative consequences.”
In “Management Options” for pain, informa-
tion from the National Library of Medicine offered
this assurance: “Opioid tolerance and physiologic
dependence are unusual in short term postopera-
tive use. . . . Likewise, psychologic dependence and
addiction are extremely unlikely to develop after
the use of opioids for acute pain.” With morphine
providing the standard choice, “opioid analgesics
are the cornerstone for management of moderate to
severe acute pain,” such as the
ACUTE PAIN a patient
with bone
CANCER might experience. Strong nar-
cotics may also be needed to aid recovery after
SUR-
GERY, especially when a procedure has been done
on a weight-bearing area such as the
LUMBAR SPINE
or
VERTEBRAE. Then, “effective use of these agents
facilitates postoperative activities such as coughing,
deep breathing exercises, ambulation, and physical
therapy.” However, “opioid administration is con-
traindicated when respiratory depression is present
(less than 10 breaths per minute).”
Dosage and Potential Side Effects
The most effective dosage for an individual varies
according to the type of condition and the level of
pain. Although no maximum amount or ceiling
has been established for a dosage of this analgesic
painkiller, reductions should occur as pain subsides
and/or side effects increase. As an online article
from the American Medical Association (AMA)
explained, “Opioid analgesics do not have an anal-
gesic ceiling effect. Therefore, dose escalation to
achieve analgesic effect is limited only by increased
O
incidence of side effects. Because not all persistent
pain syndromes respond to opioid therapy, opioid
response needs to be assessed through a therapeu-
tic trial.” To establish the initial dosage, the AMA
said, “Prior to a therapeutic trial, the patient’s pain
and function must be assessed and/or reassessed
to assist in evaluating treatment response. A pain
diary can assist in monitoring treatment effect. If
the patient’s pain does not respond to an opioid
trial, it should be stopped and an alternative thera-
peutic strategy begun. The options include a trial of
a different opioid (so-called ‘opioid rotation’).”
As a memory device for monitoring the most com-
monly experienced effects, the AMA focused on four
A’s: Analgesia, Activities, Adverse events, and Aber-
rant drug-taking behaviors. To summarize, analge-
sia refers to the degree of pain relief as well as any
improvement in
SLEEP and moods. Activities considers
whether a patient can carry out normal daily
ACTIVI-
TIES, whereas adverse events include nausea, constipa-
tion, or disruptions in sleep and sexual function. If
patients experience aberrant drug-taking behavior as a
side effect, they typically report losing their supply of
narcotics and then demand an early refill.
Statistics and Studies
A brief report in The Journal of Musculoskeletal Medi-
cine discussed “the use, effectiveness, and toxicity of
opioid analgesics in 230 spine clinic patients for 3
years.” With patients “divided into 3 groups: long-
term opioid use (3 or more consecutive months),
short-term opioid use (3 or fewer months), and no
use,” the researchers from the Minneapolis Veteran
Affairs Medical Center and University of Minne-
sota found that “use of opioid analgesics reduced
the severity of spinal pain significantly in all diag-
noses.” Furthermore, “adverse effects (e.g., con-
stipation and sedation) were reported by 58% of
the opioid-treated patients, but the symptoms were
mild. There was no significant increase in the mean
daily opioid dose over time.”
American Medical Association. “Initiating Opioid Ther-
apy,” AMA. Available online. URL: http://www.ama-
cmeonline.com/pain_mgmt/module07/06phar/04_
02.htm. Downloaded February 22, 2006.
Health Services/Technology Assessment Text. “Manage-
ment Options,” HSTAT, National Library of Medicine.
Available online. URL: http://www.ncbi.nlm.nih.gov/
books/bv.fcgi?rid=hstat6.section.32282. Downloaded
February 23, 2006.
National Institute on Drug Abuse. “NIDA InfoFacts:
Prescription Pain and Other Medications,” National
Institutes of Health (NIH.) Available online. URL:
http://www.nida.nih.gov/infofacts/PainMed.html.
Downloaded February 22, 2006.
Rasor, Joseph III, and Gerald Harris. “Opioid Use for
Moderate to Severe Pain,” Supplement 3, JAOA, The
Journal of the American Osteopathic Association 105, no. 6
(June 2005): 52–57.
Staff. “Opioid Therapy Safe and Effective for Spine Pain,”
The Journal of Musculoskeletal Medicine 22, no. 5 (May
2005): 272.
orthotics From corsets to neck braces to shoe
inserts, orthotic devices aid mobility by stabilizing
the
VERTEBRAE and correcting POSTURE in the BACK
and
SPINE. A temporary orthotic may be needed after
a
FLEXION-EXTENSION INJURY, such as a whiplash, to
stabilize the
CERVICAL SPINE and avoid further dam-
age to the injured area. With an ongoing condition
such as
ARTHRITIS that involves CHRONIC PAIN, orthotic
SHOES or inserts cushion the feet, equalize posture,
and enable a patient to continue daily
ACTIVITY. Simi-
larly, bracing can aid mobility in patients who have
DEGENERATIVE DISC DISEASE yet limit RANGE OF MOTION
in a person with
SPINAL STENOSIS.
A neck or back brace may also be used to avoid
SURGERY. Often, doctors prescribe various types of
back braces for
CHILDREN and ADOLESCENTS with
SCOLIOSIS to halt deformity during periods of bone
growth. As the online article “Adolescent Idiopathic
Scoliosis” from the North American Spine Soci-
ety (NASS) explained, “For patients with curves
of 20–40 degrees a brace is used if progression is
documented and the patient has substantial growth
remaining. Bracing will not correct the curve but
might prevent curve progression. Successful use of
a brace is dependent on the amount of time the
patient wears the brace. The brace is worn until
growth is complete and is worn between 16 and 23
hours a day.”
When surgery, such as
ARTHRODESIS, must be
performed, a brace can assist recovery by giving
the vertebrae time to fuse. As the NASS article
192 orthotics
“Spinal Fusion” said, “In addition to some restric-
tions in activity, a brace is sometimes used for the
early post operative period. There are many types
of braces available. Some are very restrictive and
are designed to severely limit motion, while oth-
ers are intended mainly for comfort and to provide
some support. The decision to use a brace or not,
and the optimal type of brace, depends upon your
surgeon’s preference and other factors related to
your surgery.”
Risks and Complications
The availability of numerous
OVER-THE-COUNTER
PRODUCTS can complicate matters since patients may
not select the best orthotic devices for their condi-
tions, thus risking damage to bones and soft tissue.
Yet prescription orthotics can be costly, and parents
must brace themselves for the possibility that their
growing children may refuse to wear the device or
slip it off when away from home.
Besides complications that arise from not wear-
ing the prescribed orthotic, patients who use braces
risk muscle loss or weakness. An article on The
Spine Institute Web site said, “Patients should avoid
becoming dependent on the lumbar corsets. If they
are used for prolonged periods (weeks and months),
the back muscles may begin to weaken and cause a
patient to be more prone to reinjury.” Nevertheless,
lumbar corsets, which can either be rigid or soft,
“provide support for the lumbar spine, help reduce
the load on back muscles, and are helpful during
episodes of acute and chronic low back pain. They
are also used for support after spine surgery, such as
discectomy, and fusion surgeries.” The same could
be said for neck bracing too.
To avoid weakening
PARASPINAL MUSCLES or neck
muscles, patients should ask their doctors about the
length of time a brace must be worn. The physician
may also prescribe physical therapy and appropri-
ate
EXERCISE to help a patient strengthen a specific
area, increase overall activity, and lessen the risk of
muscle atrophy.
Statistics and Studies
Researchers from Johns Hopkins Children’s Cen-
ter investigated the effectiveness of braces com-
monly used for scoliosis. According to the report
published by The JHU Gazette, “in a study of 276
adolescents with the most common form of scolio-
sis, the overweight were more than twice as likely
as those of normal weight to develop worsening
curvatures, despite the brace.” For about 14 hours
daily, each patient wore a back brace that extended
from beneath the arms to the hips. In each case,
“braces exert their effects on the spine through bio-
mechanical forces, which need to be of sufficient
magnitude to create and sustain curve correction.”
However, adverse effects of
WEIGHT caused the
patients to “have more and thicker soft tissue and
surface area,” which compromised the intended
effect. Therefore, “almost half of these overweight
teens eventually needed corrective surgery.”
Special Aids and Adaptations
The ease with which a patient can put on a device
helps to ensure that the orthotic will actually be
worn. Also, lightweight materials aid comfort, mak-
ing a patient more apt to wear an orthotic for the
prescribed time. Soft braces will usually be more
comfortable than hard ones, but each type of brace
must be adapted to the present need.
The SpineUniverse article “Spinal Bracing” listed
three options: flexible, semi-flexible, and rigid
braces. For example, flexible “corsets are used to
de-weight spinal structures by increasing abdomi-
nal compression.” If needed, “rigid stays and inserts
can be added to restrict motion and act as a postural
reminder.” Also, “rigid orthoses are commonly cus-
tom fabricated and provide the most support to the
area being treated.” For instance, “a body jacket
. . . controls motion in all planes.” Regardless of the
type of brace needed, patients should seek a certi-
fied orthotist (CO or CPO) to be sure they get the
most fitting device.
Collins, Jessica. “Bracing Used for Scoliosis Less Effective
in Overweight Teens,” Johns Hopkins University, The
JHU Gazette 33, no. 5 (September 29, 2003).
Falk, David. “Spinal Bracing,” SpineUniverse. Avail-
able online. URL: http://www.spineuniverse.com/
displayarticle.php/article599.html. Last updated Octo-
ber 25, 2005.
North American Spine Society. “Adolescent Idiopathic Sco-
liosis,” NASS. Available online. URL: http://www.spine.
org/fsp/prob_action-injury-scoliosis.cfm. Last updated
March 3, 2005.
orthotics 193
North American Spine Society. “Spinal Fusion,” NASS.
Available online. URL: http://www.spine.org/fsp/
prob_action-surgical-fusion.cfm. Last updated March
3, 2005.
Spine Institute, The. “Body Braces,” Saint John’s Health
Center™. Available online. URL: http://www.
espineinstitute.com/Conservative_BodyBraces.htm.
Downloaded February 23, 2006.
osteitis deformans Better known as Paget’s dis-
ease, this progressive bone disorder affects about
3 percent of
ELDERLY adults over 60 in the United
States. Although the cause of Paget’s has not been
established,
ENVIRONMENTAL INFLUENCES and GENETIC
FACTORS may trigger the disease. Any bone can be
affected, but evidence of osteitis deformans often
appears in the
SPINE with white, patchy areas char-
acteristically occurring in the skull, pelvis, and long
bones.
As the American Academy of Orthopaedic Sur-
geons (AAOS) explained, “In normal bone, a pro-
cess called remodeling takes place every day. Bone
is absorbed and then reformed in response to the
normal stresses on the skeleton.” After osteoclasts
absorb old bone cells, the osteoblasts make new
bone. However, “in Paget’s disease, osteoclasts are
more active than osteoblasts. This means there is
more bone absorption than normal. The osteoblasts
try to keep up by making new bone, but they over-
react and make excess bone that is very chaotic.
The new bone is abnormally large, is deformed and
fits together haphazardly. Normal bone has a tight
overlapping structure, like a well-constructed brick
wall. Bone afflicted by Paget’s disease has an irreg-
ular mosaic pattern, as though the bricks were just
dumped in place. The end result is bones that are
large and dense, but weak and brittle. The bone is
prone to fractures, bowing and deformities.”
Symptoms and Diagnostic Path
Initially, patients may experience no symptoms
whatsoever. Later, bone pain may occur followed
by
OSTEOARTHRITIS, gradual deformity in the spine,
and, in rare cases,
CANCER. As the disease pro-
gresses,
VERTEBRAL COMPRESSION FRACTURE and such
POSTURE problems as KYPHOSIS may hinder move-
ments and lessen mobility.
To obtain a diagnosis, X-
RAYS show abnormal
changes in bone structure, while blood tests or a
urinalysis indicate the level of bone turnover. A
physician may also request a
BONE SCAN and, some-
times, a biopsy.
Treatment Options and Outlook
Doctors often prescribe
CALCITONIN or BISPHOSPHO-
NATES to decrease bone loss, while PAIN MANAGE-
MENT may include ACETAMINOPHEN or NONSTEROIDAL
ANTI-INFLAMMATORY DRUG (NSAID) THERAPY. In
addition to medications, Holy Cross Hospital listed
self-treatments, such as “calcium, usually about
1,000–1,500 mg per day; Adequate exposure to
sunshine to promote vitamin D production in the
skin (but limit time in the sun to prevent sun burn-
ing, wrinkling and aging); Intake of adequate vita-
min D, usually about 400 mg per day (more may
be needed in older people); Regular exercise to
maintain skeletal health, joint mobility, and nor-
mal body weight; Avoidance of excess mechanical
stress on involved bones; A splint for an area at high
risk for fracture.” If an
ORTHOTIC is needed, patients
should discuss the appropriate type of bracing with
a doctor.
Risk Factors and Preventive Measures
Since Paget’s disease cannot yet be prevented, older
patients with a family history of osteitis deformans
may need a blood test every two to four years.
Adequate
EXERCISE and healthful NUTRITION, includ-
ing supplements of
CALCIUM and VITAMIN D, may
be helpful. To slow or halt the progression of the
disease, new treatments may bring new options.
For example, an article posted by News-Medical.
net reported a promising study of a drug called
zoledronic acid. According to the article, “one 15-
minute infusion of zoledronic acid 5 mg generated a
therapeutic response in 95% of patients, compared
with 75% of patients taking 30 mg/day of oral rise-
dronate, for 60 days. . . . At the six-month follow-
up, serum alkaline phosphatase (SAP) levels, a key
marker for bone turnover, were normal in 89% of
zoledronic acid patients, compared with 56% of
risedronate patients.”
For those who want to participate in ongoing
RESEARCH, the Paget Foundation welcomes contact
from patients and also persons with a family history
194 osteitis deformans
of the disease. Since Paget’s more often affects peo-
ple in northern climates, the URL below provides
contact information for The New England Registry
for Paget’s Disease of Bone.
American Academy of Orthopaedic Surgeons. “Paget’s
Disease of Bone,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=3
06&topcategory=Tumors. Downloaded February 23,
2006.
Badash, Michelle. “Paget’s Disease (Osteitis Deformans),”
Holy Cross Hospital. Available online. URL: http://
healthychoice.epnet.com/GetContent.asp?siteid=
holycross&docid=/dci/pagets. Downloaded February
23, 2006.
News-Medical.net. “First Filing for Zoledronic Acid in
Metabolic Bone Disease,” Pharmaceutical News (May 17,
2004). Available online. URL: http://www.news-medical.
net/?id=1628.
Paget Foundation, The. “Patients Needed For Research
Study.” Available online. URL: http://www.paget.org/
page.asp?page=Clinical/main_fr_bottom.asp&title=
Patients+Needed+for+Research+Studies. Downloaded
February 23, 2006.
osteoarthritis Also known as degenerative joint
disease, this most common form of
ARTHRITIS often
affects the
ELDERLY. Normally, cartilage covers the
ends of bones, allowing ease in movement, but
with osteoarthritis (OA) that protective cartilage
wears down until one bone chafes another, caus-
ing potentially disabling damage to joints and adja-
cent bones. However, OA differs from
RHEUMATOID
ARTHRITIS (RA) in that it typically does not cause the
deforming joint inflammation characteristic of RA.
According to the National Institute of Arthritis
and Musculoskeletal and Skin Diseases (NIAMS),
“osteoarthritis is one of the most frequent causes of
physical disability among adults. More than 20 mil-
lion people in the United States have the disease.
By 2030, 20 percent of Americans—about 70 mil-
lion people—will have passed their 65th birthday
and will be at risk for osteoarthritis. Some younger
people get osteoarthritis from joint injuries, but
osteoarthritis most often occurs in older people.
In fact, more than half of the population age 65 or
older would show x-ray evidence of osteoarthritis
in at least one joint. Both men and women have
the disease. Before age 45, more men than women
have osteoarthritis, whereas after age 45, it is more
common in women.” A
FLEXION-EXTENSION INJURY,
such as a whiplash or other
SPINE INJURY, can also
produce the type of joint damage that ultimately
leads to OA. Bone spurs or
OSTEOPHYTES can have
that effect too. As NIAMS explained, “Bits of bone
or cartilage can break off and float inside the joint
space. This causes more pain and damage.”
Symptoms and Diagnostic Path
Over time, degeneration can occur in any joint,
but especially in weight-bearing ones in the
BACK
or
SPINE. After EXERCISE or physical exertion, joints
may ache or stiffen, typically causing
BACKACHE or
LOW BACK PAIN. If degeneration occurs in the CER-
VICAL SPINE, the patient may experience a CERVI-
COGENIC HEADACHE or NECK PAIN. Movements may
cause a crunching sound, yet OA symptoms seldom
produce heat or inflammation as arthritis and also
rheumatoid arthritis (RA) can do. Similar to both
of those rheumatic conditions, however, osteo-
arthritis may be influenced by
GENETIC FACTORS.
Therefore, a rheumatologist or other physician may
request blood tests and a family history with X-
RAYS
to assess the affected joints.
Treatment Options and Outlook
If daily
ACTIVITY becomes increasingly difficult, a
patient may experience depression, anxiety,
TEN-
SION, or a sense of powerlessness. With early diagno-
sis and appropriate treatments though, degenera-
tion may slow down and symptoms may subside.
Usually, therapy begins with
ACETAMINOPHEN or
other
PAIN RELIEVER to keep a patient active during
the day yet able to
SLEEP at night. Sleep itself can also
be therapeutic. To aid rest, the NIAMS said, “Some
people feel better when they sleep on a firm mat-
tress or sit using back support pillows. Others find it
helps to use heat treatments or to follow an exercise
program that strengthens the back and abdominal
muscles.” To avoid joint strain, these types of exer-
cise can often be done while lying in bed.
In general,
HEAT THERAPY and swimming or
HYDROTHERAPY help OA patients to limber up with-
out straining their joints. Other forms of
COM-
PLEMENTARY AND ALTERNATIVE MEDICINE such as
osteoarthritis 195
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