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injury, ORTHOTICS, such as a back brace or neck
brace, provide temporary support of the
BACK and
spine. H
EAT THERAPY, HYDROTHERAPY, or massage
can often relieve minor aches and
ACUTE PAIN as can
OVER-THE-COUNTER and prescription strength PAIN
RELIEVERS. For other forms of PAIN MANAGEMENT,
patients may need to adapt the surrounding
ENVI-
RONMENTAL INFLUENCES and ERGONOMIC FACTORS to
fit their needs, rather than trying to adjust them-
selves to an unhealthy climate or poorly designed
chair. For most people, regular daily
ACTIVITY and
EXERCISES such as STRENGTH TRAINING can build up
paraspinal muscles while tearing down some con-
tributive sources of
PAIN.
All About Back & Neck Pain. “Paraspinal Muscles,”
DePuy Spine, Inc. Available online. URL: http://www.
allaboutbackpain.com/html/files_links/spine_anatomy_
muscle.html. Downloaded March 13, 2006.
Hayashi, Naoto, M.D., Tomohiko Masumoto, M.D.,
Osamu Abe, M.D., Shigeki Aoki, M.D., Kuni Ohtomo,
M.D., and Yasuhito Tajiri, M.D. “Accuracy of Abnormal
Paraspinal Muscle Findings on Contrast-enhanced MR
Images as Indirect Signs of Unilateral Cervical Root-
Avulsion Injury,” Radiology 223, no. 2 (May 2002):
397–402.
Leinonen, Ville M.D., Sara Maatta, M.D., Simo Taimela,
Arto Herno, Markku Kankaanpaa, Juhani Partanen,
Osmo Hanninen, and Olavi Airaksinen. “Paraspinal
Muscle Denervation, Paradoxically Good Lumbar
Endurance, and an Abnormal Flexion-Extension Cycle
in Lumbar Spinal Stenosis,” Spine 28, no. 4 (February
2003): 324–331.
Mannion, A. F., M. Meier, D. Grob, and M. Müntener.
“Paraspinal Muscle Fibre Type Alterations Associated
with Scoliosis: an Old Problem Revisited with New
Evidence,” European Spine Journal 7, no. 4 (August
1998): 289–293.
parathyroid hormone (PTH) When working well,
the body produces parathyroid hormone (PTH) to
maintain
MINERAL BALANCE and release an optimal
amount of
CALCIUM into the bloodstream. Too much
or too little PTH inclines the
VERTEBRAE to thin with
OSTEOPENIA and OSTEOPOROSIS or slant toward other
bone disorders, such as
RICKETS. Laboratory tests
can be used to assess the level of calcium and other
minerals in the blood, while
BONE MINERAL DEN-
SITY (BMD) TESTS can evaluate the SPINE and other
weight-bearing bones. If bone loss has occurred, a
synthetic form of PTH may help the body to regulate
its
BONE BUILDING abilities. Then PTH refers not to
the natural hormone, but to the category of anabolic
drugs designed to treat bone density problems.
In November 6, 2002, the Food and Drug Admin-
istration (FDA) announced the arrival of synthetic
PTH, saying, “FDA has approved teriparatide for
the treatment of osteoporosis in postmenopausal
women who are at high risk for having a fracture.
The drug is also approved to increase bone mass in
men with . . . osteoporosis who are at high risk for
fracture.” The first agent officially accepted to stim-
ulate new bone formation, “teriparatide is a por-
tion of human parathyroid hormone (PTH), which
is the primary regulator of calcium and phosphate
metabolism in bones. Daily injections of teripara-
tide” delivered in a manner similar to insulin shots
“stimulate new bone formation leading to increased
bone mineral density.”
Prescribed under the brand name Forteo, terip-
aratide has a different effect on bones from
ANTI-
RESORPTIVE DRUGS, such as BISPHOSPHONATES and
CALCITONIN. As explained in an article published
in the Cleveland Clinic Journal of Medicine, “antire-
sorptive drugs inhibit osteoclast function, decrease
turnover and remodeling, and decrease the remod-
eling space. . . . Anabolic drugs, in contrast, increase
osteoblast and osteoclast function (stimulating
osteoblasts more than osteoclasts), increase turn-
over and remodeling, and increase the remodeling
space. Therefore, anabolic drugs may prevent frac-
tures not only by increasing bone mass: they may
also change the geometry of bone.” In other words,
osteoclasts remove old or injured bone tissue, and
osteoblasts build new tissue, but for this to produce
healthy bone, the math has to be right. Patients
who cannot take antiresorptive drugs or those who
can but still remain at high risk for
FRACTURES may
find teriparatide particularly helpful.
Dosage and Potential Side Effects
According to the FDA, “Teriparatide is administered
by injection once a day in the thigh or abdomen.
The recommended dose is 20 mcg per day.” Since
growing
CHILDREN, ADOLESCENTS, and patients with
216 parathyroid hormone
OSTEITIS DEFORMANS risk the development of osteo-
sarcoma, teriparatide would not be advisable for
them. Pregnant women and patients with
CANCER or
kidney problems should avoid PTH too. The FDA also
warned, “Because the effects of long-term treatment
with teriparatide are not known at this time, ther-
apy for more than 2 years is not recommended. . . .
Most side effects reported in association with teripa-
ratide in clinical trials were mild and included nau-
sea, dizziness, and leg cramps. During the clinical
trials, early discontinuation due to adverse events
occurred in 5.6% of patients assigned to placebo
and 7.1% of patients taking teriparatide.”
Statistics and Studies
While some studies consider whether PTH should
be prescribed before or after antiresorptive drug
treatment, others focus on combination therapies.
An article in Family Practice News said, “At 6 months’
follow-up, the combination of raloxifene and para-
thyroid hormone increased bone mineral density
over baseline by a mean 6.19% at the lumbar spine
. . . as measured by dual x-ray absorptiometry.”
With bone density again measured by
ABSORPTIOM-
ETRY, “by comparison, teriparatide increased lum-
bar spine density by a mean 5.19%.” Additional
trials continue, “but the only other previous major
study of combination treatment looked at the use
of parathyroid hormone with alendronate; it sug-
gested that the addition of alendronate appeared to
inhibit the ability of parathyroid hormone to stimu-
late new bone formation.”
Until further
RESEARCH has fully determined
optimal combinations, patients should discuss with
their doctors the advantages and disadvantages rel-
evant to their particular conditions. This especially
includes individualizing a program of
NUTRITION with
appropriate amounts of calcium and
VITAMIN D.
Deal, Chad, M.D. and James Gideon, M.D. “Recombi-
nant Human PTH 1-34 (Forteo): An Anabolic Drug for
Osteoporosis,” Cleveland Clinic Journal of Medicine 70,
no. 7 (July 2003): 585–601.
Kirn, Timothy F. “Raloxifene, PTH Are Good Osteoporo-
sis Combo: Together, the Two Drugs Could Potentially
Maximize the Formation and Minimize the Resorp-
tion of Bone,” Family Practice News 35, no. 3 (February
1, 2005): 58.
U.S. Food and Drug Administration. “FDA Approves
Teriparatide To Treat Osteoporosis,” FDA Talk Paper,
November 6, 2002. Available online. URL: http://www.
fda.gov/bbs/topics/ANSWERS/2002/ANS01176.html.
Downloaded March 14, 2006.
pars defect See SPONDYLOLISTHESIS.
peak bone mass See BONE BUILDING.
pediatrics See CHILDREN, SPINAL CONCERNS FOR.
percutaneous neuromodulation therapy (PNT)
Also known as percutaneous electrical nerve stimu-
lation (PENS), this procedure offers a non-surgical
option for treating
LOW BACK PAIN (LBP). In addition,
researchers from the University of Texas Southwest-
ern Medical Center at Dallas reported on the effects
of the treatment in patients with nonradiating pain
in the
CERVICAL SPINE. Although no long-term ben-
efit has yet been documented, the report in Anesthe-
sia & Analgesia did find short-term benefits. As the
article said, “Sixty-eight patients received three dif-
ferent nonpharmacologic modalities, namely ‘nee-
dles only’ (neck), local (neck) . . . stimulation, and
remote (lower back) . . . stimulation in a random
sequence over the course of an 11-wk study period.
All treatments were given for 30 min, 3 times per
week for 3 wk, with 1 wk ‘off’ between each modal-
ity.” The researchers subsequently reported, “We
conclude that electrical stimulation” at specific lev-
els produces “greater short-term improvements in
pain control, physical activity, and quality of sleep
in patients with chronic neck pain.”
Procedure
Regardless of the area treated, the word percu-
taneous in PNT indicates penetration of the skin.
Describing this outpatient or office procedure, the
Washington State Department of Labor and Indus-
tries said, “In a manner similar to electroacupunc-
ture, PNT uses . . . needles positioned in the soft
tissues or muscles to stimulate peripheral sensory
nerves with electricity.” With needles “inserted to
percutaneous neuromodulation therapy 217
a depth of approximately 3 cm” and the electri-
cal frequency alternating between 15 and 30 Hz,
“the optimal duration of the electrical stimulation
ranges from 30 to 45 minutes.” The report also
stated, “The Food and Drug Administration (FDA)
does not regulate PNT as a therapy. However, the
agency does approve for marketing the acupunc-
ture needles and needle electrodes used in the
procedure.”
Risks and Complications
Patients with
ANKYLOSING SPONDYLITIS, CANCER, and
other conditions, such as recent
SURGERY on the
BACK, have been excluded from PNT studies. For
those who do try this form of therapy, the level of
pain relief varies. Also, insurance programs may
not cover the treatment until additional
RESEARCH
has proven its effectiveness.
Outlook and Lifestyle Modifi cations
Before trying PNT, patients should exhaust tradi-
tional forms of
PAIN MANAGEMENT as well as COM-
PLEMENTARY AND ALTERNATIVE MEDICINE (CAM)
therapies. However, PNT offers a viable option
for those who want to avoid surgery or be able to
undertake a therapeutic course of
EXERCISE.
Revord, John P., M.D. “Percutaneous Neuromodulation
Therapy (PNT)—a New, Minimally-invasive Treat-
ment for Lower Back Pain,” Spine-health. Available
online. URL: http://www.spine-health.com/research/
pnt/pnt01.html. Downloaded March 15, 2006.
Washington State Department of Labor and Industries,
Office of the Medical Director. “Technology Assess-
ment, Percutaneous Neuromodulation Therapy, Janu-
ary 13, 2004.” Available online. URL: http://www.lni.
wa.gov/ClaimsIns/Files/OMD/PensTa01132004.pdf.
Downloaded March 15, 2006.
White, P. F., W. F. Craig, A. S. Vakharia, E. Ghoname, H. E.
Ahmed, and M. A. Hamza. “Percutaneous Neuromod-
ulation Therapy: Does the Location of Electrical Stimu-
lation Effect the Acute Analgesic Response?” Anesthesia
& Analgesia 91, no. 4 (October 2000): 949–954.
peripheral neuropathy A disease or disorder of
the spinal nerves is usually classified as a neuropa-
thy, which involves many peripheral possibilities
extending from the
SPINE. To be more specific, an
article in JAOA, The Journal of the American Osteo-
pathic Association explained, “The nervous system
can be divided into two parts: the central nervous
system (CNS), which includes the brain, brainstem,
and spinal cord, and the peripheral nervous sys-
tem (PNS) that consists of the individual cranial,
motor, and sensory nerves.” Since these peripheral
nerves exit either side of the
VERTEBRAE, spinal dis-
orders can affect that sensory and motor network,
sometimes severely. To assess nerve involvement,
the JAOA article recommended the advice of a neu-
rologist.
Symptoms and Diagnostic Path
With over 100 types of peripheral neuropathies
identified, symptoms vary, but commonly include
muscle weakness and sensory disturbances. For
example, one patient may lose the protection of
pain, feeling nothing with the application of intense
heat or a pin prick, while others experience pain
with the touch of a bed sheet. Degenerative changes
in bone or muscle tone may also occur, interfering
with mobility and daily
ACTIVITY.
Causalities vary widely, so a diagnosis may be
difficult to obtain, but common causes include
bone
CANCER, ENVIRONMENTAL INFLUENCES, ERGO-
NOMIC FACTORS, FAILED BACK SURGERY, GENETIC FAC-
TORS, deficiencies in MINERAL BALANCE or NUTRITION,
SPINAL INFECTION, SPINAL INJURY, and SPINAL TUMORS.
Systemic conditions with chronic inflammation or
connective tissue damage can produce neuropa-
thies too. Therefore, blood tests may be needed to
rule out an underlying medical condition. Other
tests, such as a biopsy,
ELECTROMYOGRAM, NERVE
CONDUCTION STUDY, or nerve function tests, may be
prescribed.
Treatment Options and Outlook
Finding and treating the underlying medical cause
offers the most promising outlook. Then, a team
devoted to
PAIN MANAGEMENT can recommend rel-
evant options. For example, if
RHEUMATOID ARTHRI-
TIS produces neuropathy, the patient may need
to see a rheumatologist and also get referrals for
ACUPUNCTURE, BIOFEEDBACK, EXERCISE, MASSAGE
THERAPY, occupational therapy, or physical therapy.
A patient with neuropathies from an injury or a
218 peripheral neuropathy
POSTURE problem may need referrals from a neurol-
ogist for
ACUPRESSURE, ORTHOTICS, SPINAL MANIPULA-
TION, or SURGERY. Most patients will also be helped
by receiving nutritional counseling.
Risk Factors and Preventive Measures
Patients with inherited types of peripheral neu-
ropathy may be particularly at risk for develop-
ing
CHRONIC PAIN or numbness. According to the
National Institute of Neurological Disorders and
Stroke (NINDS), “because specific genetic defects
have been identified for only a fraction of the
known hereditary neuropathies, the Institute spon-
sors studies to identify other genetic defects that
may cause these conditions. Presymptomatic diag-
nosis may lead to therapies for preventing nerve
damage before it occurs, and gene replacement
therapies could be developed to prevent or reduce
cumulative nerve damage.” Besides that encourag-
ing
RESEARCH into peripheral neuropathies, “neuro-
pathic pain is a primary target of NINDS-sponsored
studies aimed at developing more effective thera-
pies for symptoms of peripheral neuropathy. Some
scientists hope to identify substances that will
block the brain chemicals that generate pain sig-
nals, while others are investigating the pathways by
which pain signals reach the brain.”
National Institute of Neurological Disorders and Stroke.
“Peripheral Neuropathy Fact Sheet,” National Insti-
tutes of Health. Available online. URL: http://www.
ninds.nih.gov/disorders/peripheralneuropathy/detail_
peripheralneuropathy.htm. Last updated January 25,
2006.
Scott, Kevin, M.D. and Milind J. Kothari. “Clinical Practice:
Evaluating the Patient with Peripheral Nervous System
Complaints,” JAOA, The Journal of the American Osteo-
pathic Association 105, no. 2 (February 2005): 71–83.
PET scan See POSITIVE EMISSION TOMOGRAPHY SCAN.
phosphorus With about 80 percent of this vital
mineral stored in the bones and teeth, 10 percent
in muscles, and 1 percent in nerves, dietary phos-
phorus may be in high demand. As the Centers for
Disease Control and Prevention (CDC) explained,
“Minerals are involved in a wide range of critical
functions in the human body. Calcium, phospho-
rus, and magnesium are essential in forming and
maintaining bones.” For example,
CALCIUM assists
BONE BUILDING and reduces the risk of OSTEOPOROSIS,
especially among the
ELDERLY. “In addition, calcium
plays a role in blood clotting, while phosphorus and
magnesium play essential roles in energy metabo-
lism.” CDC also said, “The electrolytes sodium and
potassium along with calcium, phosphorus, and
magnesium play important roles in neural trans-
mission, muscular activity, vascular constriction
and dilation, and maintaining normal acid-base
balance, osmotic pressure, and normal water bal-
ance.” Furthermore, “phosphorus, magnesium,
copper, and zinc act as components of enzyme sys-
tems or cofactors in enzymatic reactions. In addi-
tion, phosphorus is a component of nucleotides,
nucleic acids, and cell membranes.”
Dosage and Potential Side Effects
Well-balanced
NUTRITION brings MINERAL BALANCE
and offers a sufficient supply of phosphorus, with
almonds or other nuts providing some of the best
sources. Whole grains, lentils, raisins, and fresh pro-
duce, such as asparagus, corn, and cauliflower, have
a high content, but chocolate lovers will be glad to
know that phosphorus also comes in cocoa. Since
the mineral can be found in colas too, heavy-duty
soft drink consumption can cause an imbalance.
Should more phosphorus be needed than the diet
can provide, supplements can be taken. According
to a MedlinePlus article for the National Institutes
of Health (NIH), “The National Academy of Sciences
has recommended 700mg of phosphorus per day in
adults ages 18 years and older, including pregnant or
breastfeeding women.” For
INFANTS, CHILDREN, and
ADOLESCENTS, the NIH advised, “The recommended
adequate intake in infants 0–6 months-old is 100
mg/ day (additional phosphorus may be added
to infant formulas); the recommended adequate
intake in infants 7–12 months old is 275mg/ day;
the recommended daily intake in children ages 1–3
years-old is 460mg/ day; the recommended daily
intake in children ages 4–8 years-old is 500mg/
day; the recommended daily intake in children ages
9–18 years-old is 1,250mg/ day (including pregnant
or breastfeeding females).”
phosphorus 219
Regarding potential side effects, such as toxic-
ity, the NIH warned, “Phosphate salts should . . . be
used cautiously in those with impaired kidney func-
tion.” In general, “excessive intake of phosphates
can cause potentially serious or life-threatening
toxicity. Intravenous, oral, or rectal/enema phos-
phates may cause electrolyte disturbances including
hypocalcemia (low calcium blood levels), hypo-
magnesemia (low magnesium blood levels), hyper-
phosphatemia (high phosphorus blood levels), or
hypokalemia (low potassium levels). Calcification
of non-skeletal tissues (particularly in the kidneys),
severe hypotension (low blood pressure), dehydra-
tion, . . . acute kidney failure, or tetany,” a nervous
disorder, “can occur. Death has been reported in
infants or adults with oral, rectal, or intravenous
phosphates, particularly in those at increased risk
for electrolyte disturbances, and in those receiving
more than 45 or 90 milliliters in a 24-hour period.”
Conversely, some forms of
HERBAL THERAPY, STEROID
THERAPY, VITAMIN D, or medications may inhibit
phosphorus absorption.
Statistics and Studies
The National Institute of Child Health & Human
Development posted an online review of medical
literature regarding studies of phosphorus supple-
ments for premature infants. According to the
review, “supplementation of human milk with
minerals (either individually or as one component
of a . . . fortifier) has become common practice,
based largely on metabolic studies evaluating the
composition of human milk and the nutritional
requirements of preterm infants.” However, “there
are insufficient data on supplementation of human
milk with calcium and/or phosphorus to make
recommendations for practice.” This may be wor-
thy of further
RESEARCH since the report also said,
“Preterm infants are born with low skeletal stores
of calcium and phosphorus. Preterm human milk
provides insufficient calcium and phosphorus to
meet their estimated needs.”
Ervin, R. Bethene, Chia-Yih Wang, Jacqueline D. Wright,
and Jocelyn Kennedy-Stephenson. “Dietary Intake of
Selected Minerals for the United States Population:
1999–2000,” U. S. Department of Health and Human
Services, Centers for Disease Control and Prevention,
Advance Data From Vital and Health Statistics, no.
341 (April 27, 2004). Available online. URL: http://
www.fda.gov/ohrms/dockets/dockets/04q0098/04q-
0098-let0013-15-Ref-02-Ervin-vol16.pdf. Downloaded
March 16, 2006.
Kuschel, C. A. and J. E. Harding. “Calcium and Phos-
phorus Supplementation of Human Milk for Preterm
Infants,” National Institute of Child Health & Human
Development, National Institutes of Health. Available
online. URL: http://www.nichd.nih.gov/cochrane/
kuschel7/kuschel.htm. Downloaded March 16, 2006.
MedlinePlus. “Phosphates, Phosphorus,” U.S. National
Library of Medicine, National Institutes of Health.
Available online. URL: http://www.nlm.nih.gov/
medlineplus/druginfo/natural/patient-phosphorus.
html. Last updated December 13, 2005.
phytochemicals To squeeze in a quick quiz: Why
does a glass of orange juice often offer a better
option than a
VITAMIN C tablet? Answer: Not only
does juice taste better, the real thing has about 170
phytochemicals, including anti-inflammatory prop-
erties that may ease
ARTHRITIS and other conditions
that affect the
BACK and SPINE.
“Phyto” means plant, and natural phytochemi-
cals include vitamins, minerals, nutrients, and
other protective components such as
PHYTOESTRO-
GENS that may assist BONE BUILDING. In addition,
phytochemicals pack in antioxidants that
RESEARCH
has shown to boost the immune system and inhibit
CANCER cells.
To aid their appeal, phytochemicals also squeeze
in color power. As the article “Phytochemicals:
Guardians of Our Health” explained, “Pigments
provide a lot of color to our food and enhance the
enjoyment of the eating experience. Presently, there
are almost 2,000 known plant pigments in our food,
including over 800 flavonoids, 450 carotenoids and
150 anthocyanins. These pigments do more than
just appeal to our senses; they also protect us from
disease.” Even on the darkest eggplant or plum, a
golden hue indicates the most timely moment to
pluck or pick fresh fruit and vegetables.
Dosage and Potential Side Effects
Doctor-prescribed supplements of some phyto-
chemicals may be advisable for
INFANTS, ELDERLY
220 phytochemicals
patients, pregnant women, and patients with an ill-
ness or a medication that interferes with their nutri-
ent uptake. Supplements free of artificial additives
then provide the best option when taken according
to the recommendations on the label.
Regarding the use of supplements in the general
population, information from the American Dietetic
Association stated, “The weight of scientific evidence
indicates that the optimal approach for achieving
a health benefit from the intake of nutrients and
other physiologically active constituents is through
the consumption of a varied diet that is rich in plant
foods. In reality, each vegetable contains numerous
different nutrients and phytochemicals—a biologic
circumstance that is not currently replicated in pill
form. In addition, the assumption that a combina-
tion of plant constituents that are naturally occur-
ring is maintained at equivalent levels of biologic
activity when extracted, dried, and compacted into
pill form is likely unfounded.” Nevertheless, “phar-
maceutical companies have isolated many food
components into supplement form, including allylic
sulfides (garlic), isoflavones (soy) . . . , and glycyr-
rhizin (licorice), to name only a few. In the United
States, tens of billions of dollars are spent annually
on dietary supplements.” However, “supplements
can provide nutrients and other physiologically
active components in a potentially unbalanced and
concentrated form that may be far different from
the form used in research studies. Nutrients and
other bioactive food components that occur natu-
rally in foods act synergistically with other dietary
elements such as fiber to promote health.”
Statistics and Studies
The article “Vitamins, Carotenoids, and Phytochem-
icals” explained, “The results of studies on specific
phytochemicals are not necessarily applicable to the
vegetables or fruits that harbor small concentrations
of these chemicals. Nevertheless, it is obvious that
vegetables and fruits are healthful, which is prob-
ably due to some balance of phytochemicals, carot-
enoids, vitamins, fibers, and minerals rather than
any single substance. It should be stressed that very
little has been proven concerning the benefits of phy-
tochemical supplements sold in health food stores.
Furthermore, high concentrations of some of these
chemicals may behave like drugs and can be toxic
and possibly even contribute to cancer cell growth.”
The article added, “Most importantly, studies con-
tinue to report that the most important health ben-
efits are derived from foods containing important
nutrients, not individual supplements.” Therefore,
ideal
NUTRITION will be most likely to flourish with
colorful phytochemicals heaped from the garden
while appealingly fresh and ready to peel.
American Dietetic Association. “Functional Foods.” Avail-
able online. URL: http://www.eatright.org/cps/rde/
xchg/ada/hs.xsl/advocacy_adap1099_ENU_HTML.
htm. Downloaded March 18, 2006.
Craig, Winston J. “Phytochemicals: Guardians of Our
Health,” Vegetarian Nutrition. Available online. URL:
http://www.andrews.edu/NUFS/phyto.html. Down-
loaded March 18, 2006.
Nidus Information Services, Inc. “Vitamins, Carotenoids,
and Phytochemicals.” Available online. URL: http://
www.reutershealth.com/wellconnected/doc39.html.
Downloaded March 18, 2006.
phytoestrogens Literally meaning plant estro-
gens, phytoestrogens occur naturally in plants. As
a form of
HERBAL THERAPY and a healthful source of
NUTRITION, these plant compounds can assist BONE
BUILDING by helping the body to produce its own
estrogen. This natural source of estrogen does not
have the strength of a prescription and cannot be
stored in the body, but phytoestrogens can be read-
ily obtained in a diet flourishing with plant life.
Since phytoestrogens are not a single herb but
compounds in any plant with estrogen-producing
capabilities, they provide a safe alternative for peo-
ple who need
HORMONE REPLACEMENT THERAPY (HRT)
but want to avoid medication. Some herbalists laud
black cohosh for HRT purposes, but the herb needs
more
RESEARCH to substantiate ancient assertions
and avoid false claims. Plant estrogens differ, too,
in that they offer not an herb capsule, but a dietary
choice with the potential of slowing bone loss in
post-menopausal women inclined toward
OSTEOPE-
NIA or OSTEOPOROSIS. Such a plant-rich diet might
also provide a natural nutritional aid for
ELDERLY
patients with
OSTEITIS DEFORMANS or CHILDREN and
ADOLESCENTS with bone conditions such as OSTEO-
GENESIS IMPERFECTA.
phytoestrogens 221
Dosage and Potential Side Effects
An online article from the National Institutes of
Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) explained, “Phytoestrogens consist of
more than 20 compounds and can be found in
more than 300 plants, such as herbs, grains, and
fruits. . . . The three main classes of dietary phytoes-
trogens are isoflavones, lignans, and coumestans:
Isoflavones . . . are primarily found in soy beans
and soy products, chickpeas, and other legumes.
Lignans . . . are found in oilseeds (primarily flax-
seed), cereal bran, legumes, and alcohol (beer and
bourbon). Coumestans . . . can be found in alfalfa
and clover.” As the NIAMS also said, “Most food
sources containing these compounds typically
include more than one class of phytoestrogens.”
With the exception of food allergies, people rarely
encounter adverse side effects from consuming
whole foods unless, of course, they eat too much.
However, supplements in capsules or other forms
increase the risk of toxicity. Also, the optimal dos-
age of phytoestrogen has not been fully ascertained,
so patients would do well to proceed with caution,
perhaps asking a nutritionist or knowledgeable
pharmacist about the safe usage of supplements.
Statistics and Studies
According to the NIAMS, “much of the evidence
concerning the potential role of phytoestrogens in
bone health is based on animal studies. In fact, soy-
bean protein, soy isoflavones . . . , and coumestrol
have all been shown to have a protective effect on
bone in animals. . . . In humans, however, the evi-
dence is conflicting. Studies show that compared to
Caucasian populations, those in Hong Kong, China,
and Japan—where dietary phytoestrogen intakes
are high—experience lower rates of hip fracture.
Yet, according to the Surgeon General’s Report on
Bone Health and Osteoporosis, spine fractures are
almost as common in Asian women as they are
in white women. In addition, reports suggest that
Japanese women have a greater risk of sustaining
a vertebral fracture than Caucasian women.” One
might wonder about the difference
CALCIUM intake
makes, especially since Asian women tradition-
ally avoid dairy products in their regular diets. As
NIAMS also said, “Several studies have explored
the effects of soy isoflavones on bone health, but
results have been mixed, ranging from a mod-
est impact to no effect. Most of these studies have
serious limitations, including their short duration
and small sample size, making it difficult to fully
evaluate the impact of these compounds on bone
health.”
Studies from the United Kingdom report simi-
larly conflicting results. According to a report from
The Institute of Food Science & Technology (IFST),
“naturally occurring phytoestrogen sources in the
diet, such as soya, may have emerging potential
benefits to health. Epidemiological studies suggest
that phytoestrogen-containing foods may have a
beneficial role in protecting against cancer, osteo-
porosis, post-menopausal symptoms and cardiovas-
cular disease. There is almost no evidence though
to link the effect of phytoestrogen containing foods
to phytoestrogens alone. Many other components
of soya and linseed are biologically active in various
experimental systems and may be responsible for
the observed effects in humans.”
Besides the high quantities of phytoestrogen
found in soy products, IFST listed oat bran, wheat,
asparagus, and carrots as containing small amounts.
When one considers the
VITAMIN A in carrots and
healthful fiber in oat bran, one might wonder how
long the refrigerator will remain open to inspec-
tion before gaining credence as a well-tested way
to enjoy a healthier
BACK and SPINE.
Institute of Food Science & Technology, The. “Phytoes-
trogens,” IFST: Current Hot Topics. Available online.
URL: http://www.ifst.org/hottop34.htm. Downloaded
March 17, 2006.
National Institutes of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS.) “Phytoestrogens and Bone
Health,” Health Topics, National Institutes of Health
Osteoporosis and Related Bone Diseases, National
Resource Center. Available online. URL: http://www.
niams.nih.gov/bone/hi/bone_phyto.htm. Downloaded
March 17, 2006.
piriformis syndrome Sometimes considered a
form of
SCIATICA, this condition results from sci-
atic nerve entrapment in the piriformis muscle in
the back of the pelvis as the sciatic nerve passes
underneath or sometimes through the muscle. If
222 piriformis syndrome
that muscle gets tight, goes into a muscle spasm, or
presses on the spinal nerve,
ACUTE PAIN may radiate
into the legs and
LUMBAR SPINE.
Symptoms and Diagnostic Path
Besides producing symptoms commonly occurring
with sciatica, piriformis syndrome may mimic a
HER-
NIATED DISC as patients experience a sharp BACKACHE
or
LOW BACK PAIN. Daily ACTIVITY may increase dis-
comfort, but sedentary conditions can provoke pain
even more. A physical examination of the patient
and his or her
RANGE OF MOTION may produce a diag-
nosis. If not, X-
RAYS or other imaging tests may help
to rule out conditions with similar symptoms.
Treatment Options and Outlook
Treatments usually begin with
PAIN MANAGEMENT
to ease pain and
COLD THERAPY to reduce swelling
in the piriformis muscle. Less often,
HEAT THERAPY
can be applied to ease stiffness. S
PINAL MANIPULA-
TION and MASSAGE THERAPY may help some patients,
while others need
PAIN RELIEVERS, STEROID THERAPY,
or various types of
SPINAL INJECTIONS. To reduce mus-
cle spasms or muscle cramping, a
TRANSCUTANEOUS
ELECTRONIC NERVE STIMULATOR (TENS) unit may be
used. Most patients will also be helped with thera-
peutic
EXERCISES that involve gentle stretching.
Risk Factors and Preventive Measures
According to the National Institute of Neurologi-
cal Disorders and Stroke, “the prognosis for most
individuals with piriformis syndrome is good. Once
symptoms of the disorder are addressed, individuals
can usually resume their normal activities. In some
cases, exercise regimens may need to be modified
in order to reduce the likelihood of recurrence or
worsening.”
National Institute of Neurological Disorders and Stroke.
“NINDS Piriformis Syndrome Information Page,” National
Institutes of Health. Available online. URL: http://
www.ninds.nih.gov/disorders/piriformis_syndrome/
piriformis_syndrome.htm. Last updated January 25,
2006.
Revord, John, M.D. “Piriformis Syndrome—Another Irri-
tation to the Sciatic Nerve,” Spine-health. Available
online. URL: http://www.spine-health.com/topics/cd/
piriformis/pir02.html. Downloaded March 8, 2006.
piroxicam See NONSTEROIDAL ANTI-INFLAMMATORY
DRUG THERAPY.
pituitary dwarf See DWARFISM; GROWTH HORMONE
DISORDERS.
polyarticular juvenile rheumatoid arthritis (poly-
arthritis) See JUVENILE RHEUMATOID ARTHRITIS.
positron emission tomography (PET) scan As a
radioactive substance in the patient’s body emits
tiny little particles known as positrons, a moni-
tor shows soft tissue in that person in living color.
Brighter may not be better, though, as deepened
hues may indicate
CANCER or some type of meta-
bolic disease that affects the
VERTEBRAE.
To explain how PET works, the Radiological
Society of North America (RSNA) Web site said,
“Before the examination begins, a radioactive sub-
stance is produced in a machine called a cyclotron
and attached, or tagged, to a natural body com-
pound, most commonly glucose, but sometimes
water or ammonia. Once this substance is admin-
istered to the patient, the radioactivity localizes in
the appropriate areas of the body and is detected by
the PET scanner. . . . Different colors or degrees of
brightness on a PET image represent different levels
of tissue or organ function. For example, because
healthy tissue uses glucose for energy, it accumu-
lates some of the tagged glucose, which will show
up on the PET images. However, cancerous tis-
sue, which uses more glucose than normal tissue,
will accumulate more of the substance and appear
brighter than normal tissue on the PET images. . . .
Because PET allows study of body function, it can
help physicians detect alterations in biochemical
processes that suggest disease before changes in
anatomy are apparent with other imaging tests,
such as CT or MRI.”
Procedure
After receiving a radioactive substance intrave-
nously, the patient quietly waits for an hour or
so as the material circulates throughout the body.
Then a technician moves the examination table,
positron emission tomography (PET) scan 223
complete with patient, into a large hole where the
equipment records emissions of energy, simultane-
ously producing images of those emissions onto a
screen.
Risks and Complications
As often happens with
MAGNETIC RESONANCE IMAG-
ING (MRI), some patients feel claustrophobic dur-
ing the test. Low radiation exposure presents a very
minimal risk, but pregnant women and nursing
mothers need to avoid a PET scan if possible. Also,
patients with blood sugar problems may find their
glucose levels interfere with the test results.
Outlook and Lifestyle Modifi cations
In an article for SpineUniverse, medical writer Susan
Spinasanta said, “The amount of radioactive mate-
rial injected is . . . quickly broken down by the body
and passed within 48 hours. Temporarily increasing
fluid intake for a day or two following the test can
help facilitate elimination of the tracing substance.”
RadiologyInfo.™ “Positron Emission Tomography (PET
Imaging),” Radiological Society of North America,
Inc. (RSNA.) Available online. URL: http://www.
radiologyinfo.org/content/petomography.htm. Last
reviewed April 21, 2005.
Spinasanta, Susan. “Nuclear Imaging: PET and SPECT
Scans,” SpineUniverse. Available online. URL: http://
www.spineuniverse.com/displayarticle.php/article231.
html. Last updated December 8, 2004.
post-polio syndrome Commonly known as polio
or infantile paralysis, poliomyelitis results from a
virally induced neuromuscular disease that once
left patients with muscle atrophy or paralysis. An
injection developed by Jonas E. Salk in 1955 and an
oral polio vaccine produced by Albert B. Sabin in
1962 helped to eradicate polio in the United States.
Now, decades later, 100,000 to 200,000 patients
who previously had polio have begun to experi-
ence a worsening of their condition known as post-
polio syndrome (PPS).
Symptoms and Diagnostic Path
Muscle weakness, joint pain, and extreme fatigue
characterize post-polio syndrome. Although a rare
occurrence, some patients encounter difficulties in
swallowing or breathing. Post-polio syndrome may
also produce
POSTURE disorders, such as SCOLIO-
SIS. More often, problems arise with SLEEP, muscle
spasm, and general performance of normal daily
ACTIVITY.
Since symptoms surface many years after the
original illness, a medical history will be especially
significant. A rheumatologist may then request
laboratory tests, while a neurologist may suggest
a
COMPUTED TOMOGRAPHY (CT) SCAN or MAGNETIC
RESONANCE IMAGING to rule out other conditions.
However, a previous bout with polio does not nec-
essarily mean a person has post-polio syndrome.
Similar symptoms may instead be caused by
ARTHRI-
TIS, FIBROMYALGIA, or a degenerative condition of
the
SPINE.
According to the National Institute of Neuro-
logical Disorders and Stroke, “People who had only
minimal symptoms from the original attack and
subsequently develop PPS will most likely experi-
ence only mild PPS symptoms. People originally hit
hard by the polio virus, who were left with severe
residual weakness, may develop a more severe case
of PPS with a greater loss of muscle function, diffi-
culty in swallowing, and more periods of fatigue.”
Treatment Options and Outlook
A fact sheet from Post-Polio Health International
said, “For diagnosed post-polio syndrome, the cur-
rent treatment, which must be unique to each
individual, is the management of the symptoms.
The specific cause(s) of the symptoms need(s) to
be identified and treated and/or eliminated. Many
times the cause is overuse; however, disuse also can
result in new weakness.”
Risk Factors and Preventive Measures
Exceeding personal limits, such as engaging in pro-
longed
EXERCISE, can place a patient at greater risk
for muscle fatigue or damage. Besides developing
self-awareness, preventives include changes in
adverse
ENVIRONMENTAL INFLUENCES and ERGONOMIC
FACTORS. Well-balanced NUTRITION can be support-
ive too.
National Institute of Neurological Disorders and Stroke.
“NINDS Post-Polio Syndrome Information Page,”
224 post-polio syndrome
National Institutes of Health. Available online. URL:
http://www.ninds.nih.gov/disorders/post_polio/post_
polio.htm. Last updated March 1, 2006.
Post-Polio Health International. “Polio & Post-Polio Fact
Sheet,” PH. Available online. URL: http://www.post-
polio.org/ipn/fact.html. Last updated November 2,
2005.
posture Correctly aligned, the inward and out-
ward curves of the
CERVICAL SPINE, THORACIC SPINE,
and
LUMBAR SPINE work together to maintain
upright posture and mobility. However, a chronic
disorder, such as
DEGENERATIVE DISC DISEASE, or an
accident, such as a
FLEXION-EXTENSION INJURY, can
cause the natural curves of the
SPINE to straighten
out or reverse, thereby producing postural irreg-
ularities. For example,
KYPHOSIS gives a hump-
back appearance and
LORDOSIS a swayback look.
Both types of postural problems characteristically
present extreme bowing of a natural curvature,
whereas unequal growth on either side of the
VER-
TEBRAE produces the lateral or side-to-side curva-
ture indicative of
SCOLIOSIS. Other sources of spinal
deformities or a misshapen
BACK include ANKY-
LOSING SPONDYLITIS, BIRTH DEFECTS OF THE SPINE,
DWARFISM, aging DISCS in the ELDERLY, poor ERGO-
NOMIC FACTORS, GENETIC FACTORS, OSTEOPOROSIS,
POST-POLIO SYNDROME, and VERTEBRAL COMPRESSION
FRACTURES, each of which requires differing tests
and treatments.
Risks and Complications
Since adequate
NUTRITION and MINERAL BALANCE
assist
BONE BUILDING throughout life, young people
with
EATING DISORDERS may be particularly at risk for
developing permanent posture problems. Slouch-
ing may produce temporary problems in growing
CHILDREN and ADOLESCENTS, while posture in adults
may be temporarily affected by the adverse effects
of
WEIGHT on the spine, poorly balanced SHOES, or
improper back care during
PREGNANCY. Unless those
conditions resolve themselves, each can perma-
nently affect the ease with which a person remains
upright and in spinal balance. If vertebrae stay out
of line,
BACKACHES, CERVICOGENIC HEADACHES, LOW
BACK PAIN, and mobility issues will be more likely
to arise.
Statistics and Studies
An online article from Men’s Health offered these sta-
tistics: “The average human head weighs 8 pounds.
And if your chin moves forward just 3 inches—as
it tends to when you work at a computer—the
muscles of your neck, shoulders, and upper back
must support the equivalent of 11 pounds. That’s
a weight-bearing increase of 38 percent—often for
hours at a time. Left untreated, the effect of chronic
desk slump results in a postural dysfunction that
physical therapists call upper-cross syndrome;
you know it as rounded shoulders.” Also, “if your
shoulders are slumped forward for long periods of
time, your chest muscles become shortened. That
is, since these muscles attach to your upper arms,
the distance they need to extend when you slouch
is less than when your shoulders are drawn back.
Over time, the chest muscles adapt to this position
as their natural length, pulling your shoulders for-
ward. As a result, many of the shoulder’s stabilizers
are overstretched, which makes them weaker.”
Special Aids and Adaptations
Minor postural problems may be helped sim-
ply by shifting around and changing positions.
Some patients, however, need help to do this. For
example,
INFANTS, infirm patients, and people with
OSTEOGENESIS IMPERFECTA (OI) require special care
in positioning. As explained by the National Insti-
tute of Arthritis and Musculoskeletal and Skin Dis-
eases, “A key method for helping a person with OI
maximize strength and function is to encourage
him or her to adopt various positions throughout
the day or, in the case of an infant or young child,
to encourage parents and other caregivers to place
the child in different positions. Position changes not
only strengthen different muscle groups but also
help prevent contractures and malformations that
can limit mobility and increase pain. It is important
to keep the hips and spine as straight as possible,
prevent flattening of the back of the head from
lying supine, and promote head-turning in both
directions.”
After
SURGERY that involves a BONE GRAFT,
patients can aid their recovery by building up their
PARASPINAL MUSCLES and performing EXERCISES that
stretch the muscles. Similarly, patients with spinal-
fusing conditions such as
SPONDYLITIS can establish
posture 225
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