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of 40–50% for all clinical fractures.” Although
“it is unclear how this class of drugs reaches the
bone and how it affects bone turnover,” the article
stated, “this is an exciting area of future develop-
ment, which could offer great potential for patients
and physicians. Just as importantly, this class of
drugs is certain to open up new research opportu-
nities as investigators begin to unravel the effects of
statins on bone and the mechanisms responsible for
enhanced bone formation.”
Summarizing the most common treatments pres-
ently used in the United States, the NIH said, “Cur-
rently, estrogen, calcitonin, alendronate, raloxifene,
and risedronate are approved by the U. S. Food and
Drug Administration (FDA) for the treatment of post-
menopausal osteoporosis. Estrogen, alendronate,
risedronate, and raloxifene are approved for the pre-
vention of the disease. Alendronate is approved for
the treatment of osteoporosis in men. Alendronate
and risedronate are approved for use by men and
women” with certain types of osteoporosis.
Until recently, surgical treatment for osteopo-
rotic spine fractures was not possible since patients
with frail bones could not withstand invasive
SUR-
GERY requiring screw and plate fixation of the bone.
Now, however,
KYPHOPLASTY offers MINIMALLY INVA-
SIVE SURGERY with promising results. Nevertheless,
surgery of any kind presents an option to consider
only after nonsurgical management has failed.
Risk Factors and Preventive Measures
An article in Nursing listed factors that increase the
risks for developing osteoporosis or encountering
bone loss. For example, a sedentary lifestyle, poor
nutrition, excessive alcohol consumption, cigarette
smoking, certain medications, and products con-
taining aluminum can deplete bone mass. While
ENVIRONMENTAL INFLUENCES can certainly introduce
aluminum into the system,
OVER-THE-COUNTER PROD-
UCTS, from baking powder to deodorants, contain
that substance along with its potential for a cumula-
tive effect. Therefore, patients do well to read prod-
uct labels carefully.
People with various medical conditions and
medications face increased risks of osteoporosis
too. According to an article in Osteoporosis, Clini-
cal Updates, “treatment of secondary osteoporosis
should be focused on addressing the underlying
disease; additional interventions may then be con-
sidered.” Although “many of these conditions are
elusive, often obscured by what appears to be the
primary disease,” the article said, “virtually every
subspecialty in medicine has a disease state or
treatment that is associated with or actually causes
osteoporosis.” For example, poor
MINERAL BALANCE
brought on by malabsorption may cause bone loss
in patients with cystic fibrosis, whereas in prostate
CANCER, testosterone deficit may be a cause. Bone
loss also occurs in patients with paralysis, liver dis-
ease, renal disease, thyroid disease, and other dis-
orders.
Orthopaedic Nursing discussed the risk of bone
loss with hormone depletion. According to the arti-
cle, “the phenomenon of decreased estrogen levels
in females as it relates to bone loss is well studied:
it must be noted, however, that males also experi-
ence a decrease in estrogen . . . secondary to aging,
and this can contribute to decreased bone density
in males.” Interestingly, hormonal depletion did
not prove the case in a case cited in the report, but
rather
GENETIC FACTORS resulted in bone loss.
Genetic factors also incline people of all types
and ages toward allergies and such inflammatory
diseases as
RHEUMATOID ARTHRITIS. Since the glu-
cocorticoids prescribed to treat these conditions
often cause secondary osteoporosis, the American
College of Rheumatology (ACR) addressed “Rec-
ommendations for the Prevention and Treatment
of Glucocorticoid-induced Osteoporosis” in their
journal, Arthritis & Rheumatism. According to the
article, “Glucocorticoids alter bone metabolism
such that bone formation is reduced and resorp-
tion is increased, leading to rapid bone loss after
initiation of therapy.” Although “a number of anti-
resorptive agents are available to both prevent and
treat glucocorticoid-induced bone loss,” the ACR
advised “supplementation with calcium and vita-
min D at a dosage of 800 IU/day, or an activated
form of vitamin D (e.g., alfacalcidiol at 1 g/day
or calcitriol at 0.5 g/day), should be offered to all
patients receiving glucocorticoids, to restore nor-
mal calcium balance. This combination has been
shown to maintain bone mass in patients receiv-
ing long-term low-to-medium-dose glucocorticoid
therapy who have normal levels of . . . hormones.
However, while supplementation with calcium and
206 osteoporosis
vitamin D alone generally will not prevent bone
loss in patients in whom medium-to-high-dose glu-
cocorticoid therapy is being initiated, supplementa-
tion with calcium and an activated form of vitamin
D will prevent bone loss.”
According to the International Osteoporosis
Foundation (IOF), “a 10% loss of bone mass in
the vertebrae can double the risk of vertebral frac-
tures.” Since this places elderly men and women at
particularly high risk, the IOF advised, “In the frail
elderly, activity to improve balance and confidence
may be valuable in fall prevention.” For example,
“studies have shown that individuals who practice
tai chi have a 47% decrease in falls and 25% the hip
fracture rate of those who do not and that tai chi
can be beneficial for retarding bone loss in weight-
bearing bones in early postmenopausal women.”
Although many studies focus on older women,
CHILDREN or ADOLESCENTS with EATING DISORDERS
have a high risk of developing osteoporosis early in
life. Conversely, young people who develop health-
ful habits of nutrition and exercise can bank on their
bones being strong in later years. Weight-bearing
exercises to build bone mass include competitive
sports popular among
ATHLETES, such as golf, bas-
ketball, gymnastics, and soccer but not swimming.
While water sports help patients with joint problems,
such as
OSTEOARTHRITIS, they do not offer the type of
exercise needed to build bone. For older adults who
obtain approval from their doctors, such weight-
bearing exercises as walking, dancing, and playing
tennis can begin slowly then gradually increase to
three or four times a week in an ongoing effort to
keep bones mobile, healthy, and strong.
Agency for Healthcare Research and Quality. “Osteo-
porosis in Postmenopausal Women: Diagnosis and
Monitoring. Summary, Evidence Report/Technology
Assessment: Number 28,” AHRQ Publication Num-
ber 01-E031, February 2001. Available online. URL:
http://www.ahrq.gov/clinic/epcsums/osteosum.htm.
Downloaded March 4, 2006.
American College of Rheumatology Ad Hoc Committee
on Glucocorticoid-Induced Osteoporosis. “Recommen-
dations for the Prevention and Treatment of Glucocor-
ticoid-Induced Osteoporosis,” Arthritis & Rheumatism,
Official Journal of the American College of Rheuma-
tology 44, no. 7 (July 2001): 1,496–1,503.
American Dietary Association. “Do Men Get Osteoporo-
sis?” Available online. URL: http://www.eatright.org/
cps/rde/xchg/ada/hs.xsl/home_4058_ENU_HTML.
htm. Posted April 18, 2005.
Delmas, P. D., Zhengqing Li, and Cyrus Cooper. “Relation-
ship Between Changes in Bone Mineral Density and
Fracture Risk Reduction With Antiresorptive Drugs:
Some Issues With Meta-Analyses,” Journal of Bone and
Mineral Research 19, no. 2 (February 2004): 330–336.
Gaber, T. A.-Z. K., S. Love, and A. J. Crisp. “The High
Prevalence of Low Bone Density in Men Aged 55 Yr
and Over Presenting with Low Trauma Fractures to an
Accident and Emergency Department,” Rheumatology
42, no. 6 (2003): 807–808.
Hetzell, Carole B. “New Help for Old Bones,” Nursing 35,
no. 5 (May 2005): 20–21.
International Osteoporosis Foundation. “Facts and Statis-
tics about Osteoporosis and Its Impact,” IOF. Available
online. URL: http://www.osteofound.org/press_centre/
fact_sheet.html. Downloaded March 4, 2006.
National Institutes of Health Osteoporosis and Related
Bone Diseases National Resource Center. “Osteopo-
rosis Overview,” NIH ORBD-NRC. Available online.
URL: http://www.osteo.org/osteo.html. Downloaded
March 4, 2006.
National Osteoporosis Foundation. “Fast Facts,” NOF.
Available online. URL: http://www.nof.org/osteopo-
rosis/diseasefacts.htm. Downloaded March 4, 2006.
Office of the Surgeon General. “The 2004 Surgeon
General’s Report on Bone Health and Osteoporosis,”
U.S. Department of Health and Human Services.
Available online. URL: http://www.surgeongeneral.
gov/library/bonehealth/docs/Osteo10sep04.pdf.
Downloaded March 3, 2006.
Peer, Kimberly S. and Katherine R. Newsham. “A Case
Study on Osteoporosis in a Male Athlete: Looking
Beyond the Usual Suspects,” Orthopaedic Nursing 24,
no. 3 (May/June 2005): 193–201.
Rosen, Clifford J. and John P. Bilezikian. “Anabolic Ther-
apy for Osteoporosis,” The Journal of Clinical Endocrinol-
ogy & Metabolism 86, no. 3 (2001): 957–964.
Seeman, Ego and John A. Eisman. “Treatment of Osteo-
porosis: Why, Whom, When and How to Treat,” The
Medical Journal of Australia 180, no. 6 (March 15,
2004): 298–303.
Slovik, David M., M.D., Medical Editor. Osteoporosis: A
Guide to Prevention and Treatment. Boston, Mass.: Harvard
Health Publications, Harvard Medical School, 2005.
osteoporosis 207
Staff. “Men’s Health: The Challenge of Osteoporosis in
Elderly Men,” Patient Care 37 (June 2003): 67–70.
Staff, National Osteoporosis Foundation. “The Many
Faces Of Secondary Osteoporosis,” Osteoporosis, Clinical
Updates 3, no. 3 (2002): 1–7.
Sunyecz, John Alexander, M.D., Laurel Highlands, M.D.,
and Steven M. Weisman. “The Role of Calcium in
Osteoporosis Drug Therapy,” Journal of Women’s Health
14, no. 2 (March 2005): 180–192.
over-the-counter products Many health aids for
the
BACK and SPINE can be purchased without a pre-
scription, providing a variety of over-the-counter
(OTC) products. Some of the OTC aids mentioned
in this book include medicinal herbs for
HERBAL
THERAPY, HOMEOPATHIC MEDICINE, NONSTEROIDAL
ANTI-INFLAMMATORY DRUGS (NSAIDs), PAIN RELIEV-
ERS, ORTHOTICS, TOPICAL ANALGESICS, and nutritional
supplements of vitamins and minerals.
Risks and Complications
OTC products may not come with guarantees, but
consumers can be guaranteed problems by not read-
ing labels. Take vitamin supplements, for example,
as many people do, and the risks increase with too
much of a good thing. With water-soluble vitamins,
such as
VITAMIN B-COMPLEX or VITAMIN C, the body
usually flushes out what is not needed, but
VITA-
MIN A, VITAMIN D, or VITAMIN E hang out with body
fat and potentially reach toxic levels. Also, people
sometimes decide on their own to take a mainte-
nance dose of 81 mg of
ASPIRIN to avoid blood clots,
but if the same person takes supplements of blood-
clotting
VITAMIN K, those two OTC products may
wage a battle in the bloodstream.
Product labels give the information needed to
make an informed decision, but one little label can
not cover each contingency. For example, complica-
tions can arise if patients try to speed up the effects
of a prescribed medication with homeopathic prod-
ucts or herbs used to treat the same ailment. Never-
theless, a big rule says that no OTC product should
be taken for the same condition being treated with
pharmaceutical drugs.
To avoid the complications that arise from buy-
ing the wrong product or, worse, a dangerous
one, the American Osteopathic Association Web
site advised, “Read the labels on OTC medication
before taking them. Not only does the label pro-
vide dosage amounts and frequency, but it also
includes warnings about possible drug interactions
with other medications, food or health conditions.
As an example, many people take decongestants as
they battle colds. If these people have high blood
pressure, this could mean bad news since this OTC
medication may cause blood pressure to rise. . . .
Another safety precaution consumers can take is
to inform their physicians of all prescription and
nonprescription medications that they are cur-
rently taking, in order to make it easier for them to
spot potential interactions. This includes vitamins
as well.”
The U.S. Food and Drug Administration (FDA)
addressed concerns about adverse interactions that
occur when medications overlap. For example, “acet-
aminophen is an active ingredient found in more
than 600 OTC and prescription medicines, such as
pain relievers, cough suppressants and cold medica-
tions. It is safe and effective when used correctly, but
taking too much can lead to liver damage and even
death. The risk for liver damage may be increased
in people who drink three or more alcoholic bever-
ages per day while using acetaminophen-containing
medicines.” Inadvertently taking too many NSAIDs
produces similar risks. As the FDA said, “NSAIDs are
common medications that are used to relieve fever
and minor aches and pains. These products can
cause stomach bleeding, with an increased risk in
consumers who are over 60, are taking prescription
blood thinners, are taking steroids, or have a history
of stomach bleeding. NSAIDs may also increase the
risk of kidney problems in people with pre-existing
kidney disease, or who are taking a diuretic.”
Special Aids and Adaptations
Many useful orthotic devices, such as corsets or soft
cervical collars, can be purchased across the coun-
ter to provide temporary support. However, the
type of back brace needed for, say,
SCOLIOSIS, can
not be found without the help of an orthotist or
an orthopedist. Similarly, canes or walkers can be
purchased over the counter, but advice should first
be sought from an occupational therapist, physical
therapist, or doctor to determine the correct height
and style.
208 over-the-counter products
To encourage patients to read OTC product labels
thoroughly, the Center for Drug Evaluation and
Research (CDER) actually reminded people to put
on their glasses! Less obvious perhaps, the CDER
Web site shed light on labels, advising consumers to
look for the product name, the active ingredients or
“therapeutic substances in medicine,” the product
“category (such as antihistamine, antacid, or cough
suppressant),” and the uses, such as the “symptoms
or diseases the product will treat or prevent.” Con-
sumers especially need to be aware of any warn-
ing, such as “when not to use the product, when
to stop taking it, when to see a doctor, and possible
side effects.” Other important information might
address proper storage, whereas a list of inactive
ingredients commonly includes “substances such
as binders, colors, or flavoring.” The latter can be
particularly important in patients with food aller-
gies or other sensitivities. Also, each OTC product
should come with clear directions regarding “how
much to take, how to take it, and how long to take
it.” Adapting to those very specific instructions may
ring up the safest use for over-the-counter items.
American Osteopathic Association. “The Use of Over-
the-Counter Medicine Is on the Rise,” AOA. Avail-
able online. URL: http://www.osteopathic.org/index.
cfm?PageID=you_otcmed. Downloaded March 4, 2006.
Center for Drug Evaluation and Research. “Over-the-
Counter Medicines: What’s Right for You?” FDA.
Available online. URL: http://www.fda.gov/cder/
consumerinfo/WhatsRightForYou.htm. Last updated
August 17, 2005.
U.S. Food and Drug Administration. “FDA Launches
Campaign on OTC Pain Relief Products,” FDA Consumer
Magazine. March–April 2004. Available online. URL:
http://www.fda.gov/fdac/features/2004/204_otc.html.
Downloaded March 4, 2006.
oxaprozin See NONSTEROIDAL ANTI-INFLAMMATORY
DRUG THERAPY.
oxaprozin 209
210
Paget’s disease
See OSTEITIS DEFORMANS.
pain On a scale of one to ten, ACUTE PAIN in the
BACK or SPINE often rates high, but acute episodes
can also arrive as a dull
BACKACHE or nagging CER-
VICOGENIC HEADACHE. Likewise, CHRONIC PAIN can be
intense after a
BACK INJURY or FAILED BACK SURGERY
but may hover around the low to mid-range in
such conditions as
ARTHRITIS, OSTEOARTHRITIS, and
SPINAL STENOSIS.
To find out what hurts and where, a doctor asks
questions, such as when the pain began, how it
rates on that scale of one to 10, and what other
symptoms have been noticed. Often, the presence
or absence of additional symptoms can help to
determine an appropriate course of
PAIN MANAGE-
MENT. For example, symptoms of numbness with
intermittent but sharp pain radiating from the
LUM-
BAR SPINE may indicate SCIATICA. Specific points of
pain, often referred to as trigger points, may point
to
FIBROMYALGIA or muscle spasms, whereas radi-
ant nerve pain may suggest
SPINAL STENOSIS or
SPONDYLOLISTHESIS. LOW BACK PAIN accompanied by
urinary problems may reveal a kidney disorder. If
symptoms include a loss of function in the legs or
numbness in the groin, the condition may be diag-
nosed as
CAUDA EQUINA SYNDROME. If so, the condi-
tion often requires emergency
SURGERY in order to
recover spinal nerve function. For fever and acute
pain, an antibiotic may be prescribed to eradicate
a
SPINAL INFECTION or prevent the development of
ARACHNOIDITIS.
Regardless of the accompanying symptoms or
level of intensity, pain is the main way a body says,
“Hello. Can this area please have some attention?”
Sometimes that message requires interpretive lab-
oratory tests, X-
RAYS or other imaging tests, BONE
MINERAL DENSITY TESTS, NERVE CONDUCTION STUDIES,
or nerve function tests to identify an underlying
medical condition. Tests also clarify the treatment
options, from prescription strength
PAIN RELIEVERS
to
ACUPUNCTURE or other forms of COMPLEMENTARY
AND ALTERNATIVE MEDICINE to surgery.
Risks and Complications
With or without an underlying disorder, unchecked
pain can be physically damaging. Chronically achy
DISCS, inflamed joints, muscle STRAIN, or sore VER-
TEBRAE can cause a person to compensate by favor-
ing that area, thus creating a
POSTURE problem. Pain
also causes complications by making a person less
inclined to perform normal daily
ACTIVITY or EXER-
CISE, so the patient’s strength and mobility slowly
but steadily decrease. Then
PARASPINAL MUSCLE mass
declines. Circulation throughout the body dimin-
ishes, and pain flares. Worse, an increasingly seden-
tary lifestyle places the person at a statistically greater
risk for developing a serious medical condition.
Statistics and Studies
Natalie Frazin reported on a study linking chronic
pain to brain signals. According to that report for
The National Institute of Neurological Disorders
and Stroke (NINDS), “most studies of chronic pain
have focused on signals in the spinal cord and in the
peripheral nerves, which carry pain messages from
the limbs and other parts of the body to the spinal
cord. However, recent studies have suggested that
the brain not only receives pain signals from the
spinal cord but also undergoes changes in neuronal
connections that may permanently strengthen its
reactions to those signals. Researchers believe these
changes are key to the development of chronic
pain.” Understanding the changes in brain signals
may eventually produce new treatment options.
P
Another NINDS report, “Low Back Pain Fact
Sheet,” said, “Nearly everyone at some point has
back pain that interferes with work, routine daily
activities, or recreation. Americans spend at least
$50 billion each year on low back pain, the most
common cause of job-related disability and a lead-
ing contributor to missed work. Back pain is the
second most common neurological ailment in the
United States—only headache is more common.”
More painful statistics came from the Web site
of the American Pain Foundation: “Over 50 million
Americans suffer from chronic pain, and nearly 25
million Americans experience acute pain each year
due to injuries or surgery.” One in three citizens
loses over 20 hours of
SLEEP each week because of
pain, which undoubtedly contributes to the fact that
“lost workdays due to pain add up to over 50 mil-
lion a year.” Although the intensity of pain varies
with each causality,
CANCER pain can be especially
severe. As the foundation reported, “An estimated
70% of those with cancer experience significant
pain during their illness, yet fewer than half receive
adequate treatment for their pain.” Reasons vary,
of course, but if doctors hesitate to prescribe strong
OPIATES or OPIOIDS FOR PAIN when needed, the pri-
vate fight against cancer pain may succumb to a
public fight against drug abuse.
Special Aids and Adaptations
Some types of pain may be avoided as people use
proper techniques in
LIFTING, remain within their
LOAD TOLERANCE, and become aware of ERGO-
NOMIC FACTORS and ENVIRONMENTAL INFLUENCES
that trigger painful episodes. Lots of fresh water
and well-balanced
NUTRITION also help a body to
adapt to ever-changing conditions in life. Fitting
SHOE CHOICES aid most people, too, for example by
encouraging walking and helping the spine to stay
in proper alignment.
If good sense and caution do not prevent pain
and medical treatments fail to help,
BIOFEEDBACK
provides yet another option. Also, occupational
therapy and physical therapy may help
CHILDREN,
ADOLESCENTS, and ELDERLY patients. In discussing
three common stages of rehabilitation, the Ameri-
can Academy of Physical Medicine and Rehabilita-
tion said, “During the first phase, called the acute
phase, physiatrists treat pain and inflammation.”
With a diagnosis to guide the treatment, options
include
MASSAGE THERAPY, ACUPRESSURE, and ULTRA-
SOUND THERAPY. “In the second, or recovery, phase
of treatment, flexibility and strength are devel-
oped to get the body parts into their proper posi-
tions.” Then, “the main goal of the third phase of
treatment, the maintenance phase, is to minimize
recurrence of the problem and to prevent further
injury. This often consists of a total body fitness
program, designed to maintain body mechanics
and increase endurance after the original symp-
toms have resolved.”
American Academy of Physical Medicine and Rehabili-
tation. “Overview of Neck Pain,” AAPM&R. Available
online. URL: http://www.aapmr.org/condtreat/pain/
neckpain.htm. Downloaded March 6, 2006.
American Pain Foundation. “Fast Facts About Pain.”
Available online. URL: http://www.painfoundation.
org/page.asp?file=Library/FastFacts.htm. Downloaded
March 6, 2006.
Frazin, Natalie. “Study Links Chronic Pain to Signals in
the Brain,” National Institute of Neurological Dis-
orders and Stroke (NINDS.) Available online. URL:
http://www.ninds.nih.gov/news_and_events/news_
articles/news_article_chronic_pain.htm. Last updated
January 25, 2006.
National Institute of Neurological Disorders and Stroke
(NINDS.) “Low Back Pain Fact Sheet.” Available online.
URL: http://www.ninds.nih.gov/disorders/backpain/
detail_backpain.htm. Last updated January 25, 2006.
pain management From folk remedies to SUR-
GERY, various types of therapy work to keep pain
under control. To manage
CHRONIC PAIN, pain man-
agement specialists may be consulted. Most often
though, pain management begins at home with an
ice pack or a hot shower, but the choice of treat-
ments usually depends on the additional symp-
toms. For instance, if inflammation, swelling, or
bruising accompany pain, an appropriate treatment
may be an ice pack and
ASPIRIN or other NONSTE-
ROIDAL ANTI-INFLAMMATORY DRUG (NSAID) THERAPY.
If pain and stiffness occur without inflammation, a
hot shower or heating pad may be advisable along
with a dose of
ACETAMINOPHEN. Whichever PAIN
RELIEVER is used, the dose should not exceed what
pain management 211
the manufacturer recommends unless a doctor says
otherwise. This includes recommended doses for
pain-relieving
HOMEOPATHIC MEDICINES and HERBAL
THERAPY too.
Typically, pain management aims to reduce the
discomfort or enable a patient to tolerate pain, but
it also focuses on what causes the problem. For
example, if
ATHLETES succumb to muscle STRAIN
or manual laborers exceed their
LOAD TOLERANCE,
they might reconsider those movements. Similarly,
changing the
ENVIRONMENTAL INFLUENCES and ERGO-
NOMIC FACTORS that trigger pain may bring discern-
ible relief.
Another aspect of pain management addresses
mental health or psychological factors. For exam-
ple, a job may not manufacture pain so much as
TENSION, which, in turn, produces episodes of aches
and soreness. Dreading work can be a major source
of stress, but dreading pain can be too. In the lat-
ter case,
BIOFEEDBACK may help a patient recognize
and, thus, head off conditions leading toward dis-
comfort.
Eventually, most instances of
BACK and neck
pain resolve themselves in two to four weeks, but
CHRONIC PAIN or unexplained pain needs medical
treatment. If a fever or other worrisome symp-
toms arise, the advice of a doctor should be sought
immediately. When no other symptoms accom-
pany pain, management may include
ACUPRES-
SURE, ACUPUNCTURE, COLD THERAPY, HEAT THERAPY,
HYDROTHERAPY, MASSAGE THERAPY, ORTHOTICS, SPI-
NAL MANIPULATION, STEROID THERAPY, ULTRASOUND
THERAPY, or even another SHOE CHOICE. A night of
uninterrupted
SLEEP can make pain more manage-
able too.
If home treatments,
COMPLEMENTARY AND ALTER-
NATIVE MEDICINE (CAM), and allopathic forms of
pain management bring no relief, the focus then
shifts from pain to rehabilitation. As the direc-
tor of The National Foundation for the Treatment
of Pain explained, “No matter the severity of the
underlying pathology, improvement in the physical
function of the patient must be the goal in all but
the worst cases with multiple failed surgical proce-
dures. The patient can make demonstrable progress
in range of motion, and tolerance of activities, with
a devoted regimen of hot baths, stretches and other
physical therapies. Indeed, relief from pain should
be targeted in large part as only a means to making
physical therapy possible.”
Although uncommon,
FAILED BACK SURGERY
SYNDROME can produce such unrelenting pain that
physical therapy may not be feasible until extreme
forms of pain management have begun to take
effect. Such treatments may include a
NERVE BLOCK,
NEUROSTIMULATION, SPINAL INJECTION, or OPIOIDS FOR
PAIN, but counseling may also help some patients.
Risks and Complications
An article in the Lancet said, “Even early in the
course of an episode of low back pain, the reasons
why patients might not be recovering are complex
and include more than just the pathophysiology
of the spine. Psychological distress and misguided
beliefs about pain seem to interfere with recovery
and raise the risk of chronic disability.”
Age raises those risks since
ELDERLY patients often
experience the added complication of depression.
C
HILDREN, ADOLESCENTS, and adults with frequent
bouts of pain may feel helpless and depressed too.
In an article for the American Pain Foundation,
Dr. Scott M. Fishman explained, “Depression has
an amplifying effect on pain. By decreasing depres-
sion, we can de-amplify the sensation of pain, and
therefore decrease pain. In my opinion, decreasing
depression when it is also present with pain is a
very significant intervention for decreasing pain
itself and improving the patient’s ability to cope
with any pain sensations that they have.”
Statistics and Studies
Often, the more choices a patient has, the better
the outlook. Staying active also improves perspec-
tive and provides another form of pain manage-
ment as does appropriate
EXERCISE. An article in the
Annals of Internal Medicine said, “In chronic low back
pain, evidence strongly suggests that exercise is at
least as effective as other conservative treatments.
Individually designed strengthening or stabilizing
programs seem to be effective in health care set-
tings. . . . However, we emphasize that exercise
therapy is not the same as advice to stay active,
which is a recommended treatment strategy in
acute populations.”
Unfortunately, all populations may not receive
the same quality of treatment. As an article in The
212 pain management
Journal of the American Osteopathy Association (JAOA)
reported, “Disparities clearly exist in the way in
which certain patients receive treatment for their
pain. Physicians need to be aware of these problems
so they can provide proper care to all their patients,
with special attention to racial and ethnic minorities,
women, and substance abusers. Only when physi-
cians acknowledge and understand such disparities
and barriers can they begin to evaluate and improve
on their own practices of pain management.”
A patient’s anticipation of pain may also con-
tribute to its intensity. According to a report posted
online by the National Institute of Neurological Dis-
orders and Stroke, “people with decreased expecta-
tions for pain reported less pain. At the same time,
activity decreased in areas of the brain important to
both sensory and emotional processing of pain. . . .
These lower expectations reduced reports of pain
by more than 28 percent.”
Special Aids and Adaptations
Adequate rest, exercise,
NUTRITION, and, sometimes,
distractions aid pain reduction. In addition, almost
everyone manages pain better if someone else
understands what is happening each day. Empathy
brings the aid of comfort but also produces creative
ideas and workable solutions that can be adapted to
fit the individual. This can be particularly important
in helping patients deal with pain that does not go
away. The Partners Against Pain Web site posted a
“Patient Comfort Assessment Guide” developed by
Dr. Elizabeth J. Narcessian to help caretakers assess
the level of discomfort their partners experience.
To start family discussions and also clarify how the
patient feels, the assessment offered such questions
as, “What time of day is your pain the worst?” and,
“What makes your pain better?” By noting relevant
symptoms and evaluating the degree to which pain
interferes with normal daily
ACTIVITY, patients can
help their partners understand how to assist in
managing and, perhaps, overcoming the discom-
forts of that day.
Fishman, Scott M., M.D. “Antidepressants for Pain,” Pain
Question & Answer, American Pain Foundation. Avail-
able online. URL: http://www.painfoundation.org/page.
asp?file=QandA/Anti-depressants.htm. Downloaded
March 11, 2006.
Hay, E. M., R. Mullis, M. Lewis, K. Vohora, C. J. Main,
P. Watson, K. S. Dziedzic, J. Sim, C. M. Lowe, and
P. R. Croft. “Comparison of Physical Treatments versus
a Brief Pain-management Programme for Back Pain in
Primary Care: a Randomised Clinical Trial in Physio-
therapy,” Lancet 365, no. 9,476 (June 11, 2005): 2,024–
2,030.
Hochman, J. S., M.D. “Essential Considerations in the
Treatment of Intractable Pain,” The National Founda-
tion for the Treatment of Pain. Available online. URL:
http://www.paincare.org/pain_management/essential/
factors.html. Downloaded March 11, 2006.
Jones-London, Michelle D., “Expectations of Pain: I
Think, Therefore I Am,” National Institute of Neu-
rological Disorders and Stroke (NINDS.) Available
online. URL: http://www.ninds.nih.gov/news_and_
events/news_articles/news_article_pain_perception.
htm. Last updated February 15, 2006.
Narcessian, Elizabeth J., M.D. “Patient Comfort Assess-
ment Guide,” Partners Against Pain®. Available online.
URL: http://www.partnersagainstpain.com/printouts/
pcag.pdf. Downloaded March 11, 2006.
Paulson, Margaret III, and Anthony H. Dekker. “Health-
care Disparities in Pain Management,” The Journal of
the American Osteopathy Association, JAOA 105, no. 6,
supplement 3 (June 2005): 14–17.
pain relievers As the phrase implies, this form of
PAIN MANAGEMENT primarily aims to relieve PAIN.
While
TOPICAL ANALGESICS may be rubbed onto the
skin to reduce muscle soreness, most pain reliev-
ers come packaged in caplets, capsules, liquids, or
pills to be taken orally. These
OVER-THE-COUNTER
PRODUCTS (OTC) and prescription strength drugs
commonly include
ACETAMINOPHEN unless inflam-
mation accompanies the pain. If so, the preferred
medication may be
ASPIRIN, IBUPROFEN, NAPROXEN,
or other
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID).
For
CHILDREN and ELDERLY patients, acetaminophen
has become the most popular choice of pain relievers.
For severe
CHRONIC PAIN, a physician may prescribe
CYCLOOXYGENASE (COX-2) INHIBITORS, OPIATES or OPI-
OIDS FOR PAIN, or STEROID THERAPY. However, patients
with allergies or sensitivities to medication usually
prefer pain relief from
HOMEOPATHIC MEDICINES or
kitchen herbs. Although studies are still needed to
pain relievers 213
evaluate the effectiveness of homeopathic products
and
HERBAL THERAPY, people have used willow bark
for centuries to relieve pain. Besides lauding that
forerunner of aspirin, some people find pain relief
with culinary usage of cayenne pepper, ginger,
and turmeric. Those choice herbs may or may not
eliminate pain, but they do spice foods and con-
versations about the ancient connections between
culinary and medicinal arts.
Risks and Complications
According to the Food and Drug Administration
(FDA), “pain reliever and fever reducer drug prod-
ucts have been available for many years without a
prescription. These products are safe and effective
when used by consumers properly.” Nevertheless,
“the FDA believes that consumers need to know
that pain relievers or fever reducers can cause seri-
ous side effects when used improperly. FDA urges
people to read the labels of all the OTC medicines
they take to know how to take them properly.”
Patients would be well advised to read product
labels, too, since many OTC medicines include acet-
aminophen and NSAIDs. If patients take those in
addition to a regular dosage of the pure product,
they instantly have too much, thus increasing the
risk of complications, such as stomach bleeding
from an NSAID or liver damage from acetamino-
phen. In addition, herbal pain relievers should not
be taken with any over-the-counter or prescription
pain medications.
Opioids often interact with other medications
too. As the National Institute on Drug Abuse (NIDA)
warned, “opioid medications can affect regions of
the brain that mediate what we perceive as plea-
sure, resulting in the initial euphoria that many
opioids produce. They can also produce drowsi-
ness, cause constipation, and, depending upon the
amount taken, depress breathing. Taking a large
single dose could cause severe respiratory depres-
sion or death.” To avoid patient addiction and also
the complications that arise from rapid withdrawal,
“individuals taking prescribed opioid medications
should not only be given these medications under
appropriate medical supervision, but also should be
medically supervised when stopping use in order
to reduce or avoid withdrawal symptoms. Symp-
toms of withdrawal can include restlessness, mus-
cle and bone pain, insomnia, diarrhea, vomiting,
cold flashes with goose bumps (‘cold turkey’), and
involuntary leg movements.”
Statistics and Studies
According to the NIDA, “studies have shown that
properly managed medical use of opioid analge-
sic compounds is safe and rarely causes addiction.
Taken exactly as prescribed, opioids can be used to
manage pain effectively.”
Similarly, all pain relievers, including OTC prod-
ucts, must be taken as prescribed. As an article in
Shape magazine reported, “a study in the journal
Neurology found that when compared with people
who used over-the-counter and/or prescription
pain relievers as directed (or didn’t use them at all),
those who took too much of the drugs were more
likely to have chronic migraine headaches, as well
as more neck and lower back pain.” Also, “a recent
survey by the American Gastroenterological Associ-
ation (AGA) showed that 44 percent of people said
they took more than the recommended doses.”
Special Aids and Adaptations
In discussing the
RESEARCH they sponsor, the National
Institute of Neurological Disorders and Stroke
(NINDS) said, “Scientists are working to develop
potent pain-killing drugs that act on receptors for the
chemical acetylcholine. For example, a type of frog
native to Ecuador has been found to have a chemical
in its skin called epibatidine, derived from the frog’s
scientific name, Epipedobates tricolor. Although
highly toxic, epibatidine is a potent analgesic and,
surprisingly, resembles the chemical nicotine found
in cigarettes. Also under development are other less
toxic compounds that act on acetylcholine receptors
and may prove to be more potent than morphine
but without its addictive properties.”
While new aids continue to become available,
some patients have turned to a source of pain relief
that may have been used for over 9,000 years. As
reported on the University of Maryland Web site,
“Capsaicin in cayenne pepper has very power-
ful pain-relieving properties when applied to the
surface of the skin. Laboratory studies have found
that capsaicin relieves pain by destroying a chemi-
cal known as substance P that normally carries pain
messages to the brain. This appears to be true when
214 pain relievers
applied topically,” especially for such conditions as
RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, BACKACHE,
and the pain of an overworked muscle.
Center for Drug Evaluation and Research. “Questions and
Answers on Using Over-the-Counter (OTC) Human
Drug Products Containing Analgesic/Antipyretic
Active Ingredients Safely,” Food and Drug Admin-
istration (FDA), Department of Health and Human
Services. Available online. URL: http://www.fda.gov/
cder/drug/analgesics/QandAanalgesics.htm. Created
January 22, 2004.
National Institute of Neurological Disorders and Stroke
(NINDS.) “Pain: Hope Through Research.” Available
online. URL: http://www.ninds.nih.gov/disorders/
chronic_pain/detail_chronic_pain.htm. Last updated
January 25, 2006.
National Institute on Drug Abuse (NIDA.) “NIDA Info-
Facts: Prescription Pain and Other Medications,”
National Institutes of Health, U.S. Department of
Health and Human Services. Available online. URL:
http://www.nida.nih.gov/Infofacts/Painmed.html.
Last updated April 21, 2005.
University of Maryland Medical Center. “Cayenne,” Cen-
ter for Integrative Medicine. Available online. URL:
http://www.umm.edu/altmed/ConsHerbs/Cayennech.
html. Downloaded September 12, 2006.
paraspinal muscles Up and down the SPINE, pairs
of paraspinal muscles attach to either side of the
VERTEBRAE, keeping a body upright and moving. If,
however, an injury occurs in a
DISC, vertebral bone,
or connective soft tissue, this group of muscles pro-
tectively contracts around the damaged area, caus-
ing muscle spasm.
An online article on the Web site All About Back
& Neck Pain explained, “Muscles that are in spasm
produce too much lactic acid, a waste product from
the chemical reaction inside muscle cells. When
muscles contract, the small blood vessels traveling
through the muscles are pinched off (like a tube
pinched between your thumb and finger), which
causes a build up of lactic acid. If the muscle cells
cannot relax and too much lactic acid builds up,
it causes a painful burning sensation.” As muscles
relax, normal blood flow rinses away the build-up
of lactic acid. For that to happen though, a warm
bath,
MASSAGE THERAPY, MUSCLE RELAXANT, or restful
SLEEP may be needed, and an appropriate change in
NUTRITION may restore MINERAL BALANCE.
Risks and Complications
P
OSTURE problems, such as KYPHOSIS and LORDO-
SIS, tip musculoskeletal balance, causing CHRONIC
PAIN or BACKACHE in the THORACIC SPINE and lum-
bar region. T
ENSION in paraspinal muscles can also
cause
VERTEBRAL SUBLUXATION that throws the spine
out of alignment. In addition, a
FLEXION-EXTENSION
INJURY, such as a whiplash, can misalign the spine
and strain the paraspinal muscles.
Statistics and Studies
Researchers from Switzerland studied the effects of
SCOLIOSIS on paraspinal muscles then reported in the
European Spine Journal: “In scoliosis, the spinal mus-
culature is most affected on the concave” or curved-
in “side. . . . The muscle adopts a ‘faster’ . . . profile
. . . perhaps consequent to a local change in activity
on this side of the spine following progression of the
curve. Less marked changes, in the same direction,
are also evident on the convex,” or rounded, “side;
these may be the result of general disuse of the para-
spinal muscles associated with the spinal deformity.”
According to an article in Spine, researchers used
ELECTROMYOGRAM to study effects of SPINAL STENOSIS
on paraspinal muscles then reported, “Abnormal
findings in needle electromyography of the paraspi-
nal muscles were observed in 18 of the 22 (81.8%)
examined patients. Abnormal . . . activation of the
paraspinal muscles was observed in all the exam-
ined patients.”
A study in Radiology magazine focused on the accu-
racy of
MAGNETIC RESONANCE IMAGING (MRI or MR)
used when a neck injury involved paraspinal muscles
in the
CERVICAL SPINE. The article concluded, “This
study shows that contrast-enhanced MR findings in
the paraspinal muscles are accurate for diagnosis of
cervical root avulsion,” or tearing of the spinal nerves
in the neck. Apparently, this type of enhancement
“demonstrates the abnormality more accurately than
do other paraspinal muscle findings.”
Special Aids and Adaptations
Paraspinal aids depend on what ails this group
of muscles. With a posture problem or whiplash
paraspinal muscles 215
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