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good postural habits to aid RANGE OF MOTION and
flexibility. As an online article from the Spondylitis
Association of America (SAA) explained, “People
with spondylitis often are painfully aware of the
strains imposed by gravity. A vicious pain-poor
posture cycle begins because of a tendency to bend
over when experiencing pain in the spine, further
increasing the amount of strain on the spine.” Vari-
ous forms of
PAIN MANAGEMENT, such as NONSTEROI-
DAL ANTI-INFLAMMATORY DRUG (NSAID) THERAPY,
may enable a person to move about more and
maintain flexibility. As the association said, most
patients can be helped if they “Think Tall.” The
SAA also advised, “Hold your head in a balanced
manner over the trunk in a sitting or standing
position. The chin should be horizontal and paral-
lel to the floor, drawn back slightly and centered.
Try to stand, walk and sit ‘tall’ at all times.” To do
this, some patients may need the aid of a cane or
walker, while others may require special
ORTHOTIC
devices to assist them in remaining upright and on
the move.
Gonzalez, Lorenzo. “Are Your Shoulders In a Slump?”
Men’s Health. Available online. URL:http://www.
menshealth.com/cda/article.do?site=MensHealth&cha
nnel=fitness&category=muscle.building&topic=arms&c
onitem=98b871957cb98010VgnVC M200000cee793cd_
___&cm_mmc=AbsDietNL-_-2006_02_06-_-Fitness-_-
Are_Your _Shoulders_in_a_Slump? Downloaded March
21, 2006.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases. “Therapeutic Strategies for Osteogen-
esis Imperfecta: A Guide for Physical Therapists and
Occupational Therapists,” NIAMS, National Institutes
of Health. Available online. URL: http://www.niams.
nih.gov/bone/hi/osteogenesis/oi_pt_ot_guide.htm.
Downloaded March 21, 2006.
Spondylitis Association of America. “Posture.” Avail-
able online. URL: http://www.spondylitis.org/patient_
resources/posture.aspx. Downloaded March 21, 2006.
potassium Most fresh foods contain this mineral
element that helps to maintain overall health and
prevent
OSTEOPOROSIS and other problems of the
BACK and SPINE. Along with CALCIUM and MAGNE-
SIUM, potassium aids the MINERAL BALANCE needed
for spinal nerve impulses and normal functioning
of
PARASPINAL MUSCLES. In conjunction with sodium
and chloride, potassium regulates the acid-alkaline
balance in the body. Adequate supplies of these
minerals and ample
WATER strengthen bones and
electrify the body with the energy needed for daily
ACTIVITY.
The George Mateljan Foundation explained,
“Potassium, sodium and chloride comprise the
electrolyte family of minerals. Called electrolytes
because they conduct electricity when dissolved in
water, these minerals work together closely. About
95% of the potassium in the body is stored within
cells, while sodium and chloride are predominantly
located outside the cell.”
Dosage and Potential Side Effects
Natural dietary sources of potassium abound with
good
NUTRITION, but strenuous EXERCISE and some
diuretics can quickly deplete the levels a body
needs. A diet centered on fast foods also causes
loss of potassium and other nutrients too, which
may account for the seemingly epidemic symp-
toms in this country of muscle weakness, mental
confusion, mood swings, and fatigue. Overexer-
tion, nausea, and diarrhea can also result from
lowered levels of potassium. However, too much
potassium can cause muscle spasms. If those
spasms affect cardiac muscle, a heart attack may
occur.
Although potassium supplements may be needed
temporarily, multivitamin supplements that include
minerals but remain free of preservatives and dyes
would provide a safer and better-balanced option
for regular usage. Better yet would be a diet rich in
fresh fruits and vegetables. For those who cannot
deal with, say, spinach, similar amounts of potas-
sium occur in lima beans, soybeans, pinto beans,
and winter squash. Bananas and cantaloupe have
only about half the potassium found in chard or
spinach, but cooking greens will drain about half of
the mineral, making uncooked fruit a more delec-
table choice.
Statistics and Studies
According to the American Dietetic Association,
“The Institute of Medicine of the National Acad-
emies of Science recently issued recommendations
226 potassium
for sodium and potassium intake levels, saying
healthy adults between 19 and 50 should consume
about 1,500 milligrams of sodium per day and 4,700
milligrams of potassium.” Not surprisingly, Ameri-
cans typically consume too much sodium in table
salt, canned vegetables, heavily processed foods,
and other salty products with too little potassium
on the side. To avoid this imbalance, most studies
suggest a diet of fresh produce and whole grains as
close to their natural state as individual taste buds
and tummies can tolerate.
American Dietetic Association. “Are You Getting Enough
Potassium? Maybe Not.” Available online. URL:
http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/
home_4149_ENU_HTML.htm. Downloaded March
16, 2006.
———. “Sodium and Potassium: How Much Is Too
Much?” Available online. URL: http://www.eatright.
org/cps/rde/xchg/ada/hs.xsl/home_4466_ENU_
HTML.htm. Downloaded March 16, 2006.
WorldsHealthiestFoods.com. “Potassium,” WHF, The
George Mateljan Foundation. Available online. URL:
http://www.whfoods.com/genpage.php?tname=
nutrient&dbid=90. Downloaded March 16, 2006.
Pott’s disease See SPINAL TUBERCULOSIS.
prednisone See STEROID THERAPY.
pregnancy, back care during Obvious changes
occur during pregnancy with added
WEIGHT on
the
LUMBAR SPINE often causing BACKACHES, LOW
BACK PAIN, muscle STRAIN, and, occasionally, POS-
TURE problems such as LORDOSIS or swayback. Less
obviously, hormonal changes and production of
new hormones by the placenta enable the mus-
culoskeletal system to accommodate an unborn
child. Those hormones not only affect moods but
allow the ligaments that hold the pelvic bones
together to expand enough for an
INFANT to be
born. However, the same hormones can also
cause the
VERTEBRAE to shift and the SPINE to
become less stable. As ligaments loosen to allow
for expansion, instability may be keenly felt in the
SACRAL VERTEBRAE with something akin to SACRO-
ILIAC JOINT PAIN SYNDROME.
Risks and Complications
Women with
SCOLIOSIS, OSTEOPENIA, OSTEOPOROSIS,
DEGENERATIVE DISC DISEASE, or other pre-existing
conditions that affect the spine may be at particu-
larly high risk for
BACK problems during pregnancy.
To assess a serious back condition or a
SPINAL INJURY,
an X-
RAY or other imaging device that uses radiation
may be needed. This radiation exposure remains at
such a low level that the mother herself will prob-
ably not be affected. However, the Centers for Dis-
ease Prevention and Control (CDC) studied the risks
that tests involving radiation present to a fetus. As
the CDC reported, “Because the human embryo or
fetus is protected in the uterus, a radiation dose to a
fetus tends to be lower than the dose to its mother
for most radiation exposure events. However, the
human embryo and fetus are particularly sensi-
tive . . . and the health consequences of exposure
can be severe, even at radiation doses too low to
immediately affect the mother. Such consequences
can include growth retardation, malformations,
impaired brain function, and cancer.” Nevertheless,
“beyond about 26 weeks, the fetus is less sensitive
to the noncancer health effects of radiation expo-
sure than in any other stage of gestation.”
If pregnancy continues beyond normal term,
womb crowding can cause
BIRTH DEFECTS OF THE
SPINE in an otherwise healthy newborn. One risk, for
example, includes growth restrictions that increase
the likelihood of a
BRACHIAL PLEXUS INJURY in the
newborn. As the Agency for Healthcare Research
and Quality (AHRQ) reported, “Prolonged preg-
nancy has traditionally been defined as a pregnancy
that extends 2 weeks or more beyond the estimated
day of confinement, or 42 weeks. Approximately 18
percent of pregnancies in the United States extend
beyond 41 weeks, and 7 percent extend beyond 42
weeks.”
For the mother, a prolonged pregnancy will
be likely to intensify spinal
PAIN, but new moth-
ers may be at risk for acquiring new problems too.
According to statistics posted by Birthsong Child-
birth Education & Support Services, “10% of new
moms develop a backache for the first time that
lasts at least 6 weeks. Among women who’d had
pregnancy, back care during 227
epidurals, the number jumps to 18%. This may be
due to poor positioning during birth: women with
epidurals may not be able to sense discomfort when
they are in a position which is straining muscles,
so support people need to pay attention to keeping
mom in a comfortable, healthy position.”
In addition to those concerns during the birth
process, sensitivity to medication can complicate
the birth or cause spinal problems for the mother.
For example, an
EPIDURAL INJECTION to ease labor
pain can give birth to an allergic response with
the potential for serious complications, such as
ARACHNOIDITIS.
Statistics and Studies
An article on the Spine-Health Web site reported, “It
is estimated that between 50% and 80% of women
experience some form of back pain during their
pregnancy, ranging from mild pain associated with
specific activities to acute back pain that can become
chronic.” More specifically, “studies show that low
back pain usually occurs between the fifth and sev-
enth month of pregnancy, but can begin as early as
eight to twelve weeks into your pregnancy.”
Special Aids and Adaptations
While
EXERCISE can strengthen PARASPINAL MUS-
CLES, an ORTHOTIC device may be needed to pro-
vide lumbar support throughout the pregnancy.
Also, sensible
SHOE CHOICES, such as a walking shoe
with low heels and padded insole, can provide
extra cushioning for the vertebrae, relieve pressure
on spinal
DISCS, and generally aid vertebral align-
ment. If exercise proves too painful on the ground,
adaptations can be made with
HYDROTHERAPY or
walking in waist-high water across a swimming
pool. As another option to increase daily
ACTIVITY
and decrease back pain, some women can perform
strengthening exercises, such as pelvic tilts and leg
raises, while lying in bed.
To aid
SLEEP, resting on one side with a pil-
low between the knees may help to alleviate low
back pain. N
UTRITION can also be adapted with an
emphasis on natural food sources that provide
MIN-
ERAL BALANCE and ample CALCIUM. A physician may
prescribe a natural vitamin and mineral supple-
ment for some pregnant or lactating women, but
in general, a variety of fresh foods and dairy prod-
ucts provides the nutrients needed to sustain both
mother and child.
Agency for Healthcare Research and Quality. “Manage-
ment of Prolonged Pregnancy,” Evidence Report/Tech-
nology Assessment: Number 53. Available online. URL:
http://www.ahrq.gov/clinic/epcsums/prolongsum.
htm. Downloaded March 22, 2006.
Centers for Disease Control and Prevention. “Prenatal
Radiation Exposure: A Fact Sheet for Physicians,” CDC,
Department of Health and Human Services. Available
online. URL: http://www.bt.cdc.gov/radiation/prena-
talphysician.asp. Last updated March 23, 2005.
Mehl-Madrona, Lewis, M.D. and Morgan Mehl-Madrona.
“Medical Risks of Epidural Anesthesia During Child-
birth,” Birthsong Childbirth Education & Support
Services. Available online. URL: http://onyx-ii.com/
birthsong/page.cfm?epidural. Downloaded March 22,
2006.
Montgomery, Stephen P., M.D. and Linda Sawyer. “Back
Pain in Pregnancy,” Spine-Health.com. Available
online. URL: http://www.spine-health.com/topics/cd/
pregnancy/preg02.html. Downloaded March 22, 2006.
pressure point See ACUPRESSURE.
primary hyperparathyroidism A fact sheet from
the National Institutes of Health (NIH) Osteoporo-
sis and Related Bone Diseases explained this hor-
monal disorder: “Primary hyperparathyroidism is a
hormonal problem due to one or more parathyroid
glands producing too much parathyroid hormone.
Parathyroid glands, four small glands located in the
neck near the thyroid gland, keep blood calcium
from falling below normal. Rarely, there are more
than four of these glands, and they may be in other
parts of the neck or in the chest. In 80 to 85 per-
cent of patients with primary hyperparathyroid-
ism, a single gland is affected. In 15 to 20 percent
of patients, two or more glands are affected. The
affected gland(s) enlarge and produce too much
parathyroid hormone. As a result, blood calcium
becomes high, bones may lose calcium, and kid-
neys may excrete too much calcium.” According to
228 pressure point
the NIH, “in the United States, 28 out of 100,000
people develop primary hyperparathyroidism each
year. Women outnumber men 3 to 1, and fre-
quency increases with age. In most cases, the cause
is unknown,” but
CANCER, GENETIC FACTORS, and
previous exposure to radiation may produce this
hormonal imbalance.
Symptoms and Diagnostic Path
Often, bone loss occurs before symptoms pres-
ent themselves. If too much
CALCIUM leaves the
bones and flows into the bloodstream, the patient
may experience joint pain, muscle weakness, and
fatigue. To aid a diagnosis, various laboratory tests
can evaluate the
MINERAL BALANCE in the body,
whereas a
BONE MINERAL DENSITY TEST can assess
bone loss.
Treatment Options and Outlook
In some instances,
SURGERY will be required to
remove the affected gland. While
BISPHOSPHONATES
and
HORMONE REPLACEMENT THERAPY cannot cor-
rect the causal factor, the drugs may be prescribed
to treat or delay the development of secondary
OSTEOPOROSIS.
Risk Factors and Preventive Measures
To prevent additional problems from occurring,
the NIH recommended, “Patients should drink
enough fluid to avoid dehydration, which leads
to an increase in blood calcium. To avoid wors-
ening calcium levels, patients should get regular
exercise and avoid immobilization. A diet includ-
ing approximately 1,200 mg of calcium is recom-
mended. Avoiding calcium-containing foods could
further stimulate the parathyroid glands.” In gen-
eral, proper
NUTRITION, daily ACTIVITY, and EXERCISE
offer ongoing
BONE BUILDING possibilities.
National Institutes of Health Osteoporosis and Related
Bone Diseases. “Information for Patients about Primary
Hyperparathyroidism,” NIH Fact Sheet. Available online.
URL: http://www.osteo.org/newfile.asp?doc=p112i&
doctitle=Primary+Hyperparathyroidism&doctype=HTML
+Fact+Sheet. Downloaded March 7, 2006.
prolapsed disc See HERNIATED DISC.
pulled muscle See STRAIN.
pulled muscle 229
230
quantitative computed tomography
(QCT) This
noninvasive
BONE MINERAL DENSITY (BMD) TEST
offers an alternative to dual X-ray
ABSORPTIOMETRY
(DEXA or DXA) in assessing bone mass. Although
less available and more expensive, quantitative
computed tomography (QCT) provides an accurate
picture of bone patterns and bone loss. For exam-
ple, an article in Osteoporosis International reported
on a study of 64 patients with a
SPINAL CORD injury
(SCI). Using QCT to measure bone density in the
SPINE, “Our results indicate that QCT reveals osteo-
porosis of the spine after SCI, in contrast to DXA.”
Therefore, “we postulate that QCT is more valu-
able for evaluating spinal osteoporosis following
SCI than DXA and thus recommend QCT for spinal
BMD studies in SCI.”
Procedure
Patients can usually keep on street clothing, minus
metal and jewelry, for a QCT, which takes about 15
minutes. As the person reclines on a padded table,
an imaging device passes over the body and records
data, usually from the hips and spine.
Risks and Complications
A QCT requires less radiation than X-
RAYS, thus
presenting minimal risk of exposure. Also, a QCT
requires no injections or contrast dyes that can pro-
duce complications in sensitive patients.
Outlook and Lifestyle Modifi cations
The Journal of Bone and Joint Surgery published a
promising outlook from Dr. Brian D. Snyder and
associates on predicting
FRACTURES with QCT.
According to an online summary of the article,
“The authors found that standard radiographic
criteria . . . were weak predictors of fracture risk,
both with regard to sensitivity (28% to 83%) and
specificity (6% to 78%). In sharp contrast, all . . .
parameters that were obtained with use of quanti-
tative computed tomography were 100% sensitive
and were 44% to 89% specific.” In addition, the
original study mentioned the promising develop-
ment of equipment intended to eliminate the need
for radiation exposure in testing bone density.
Liu, C. C., D. J. Theodorou, S. J. Theodorou, M. P. Andre,
D. J. Sartoris, S. M. Szollar, E. M. Martin, and L. J. Def-
tos. “Quantitative Computed Tomography in the Eval-
uation of Spinal Osteoporosis Following Spinal Cord
Injury,” Osteoporosis International 11, no. 10 (October
2000): 889–896.
Rimnac, Clare M. “Commentary & Perspective on ‘Pre-
dicting Fracture Through Benign Skeletal Lesions with
Quantitative Computed Tomography’ by Brian D. Sny-
der, MD, PhD, et al.,” The Journal of Bone and Joint Sur-
gery, JBJS, 88, no. 1 (January 2006): 55–70. Available
online. URL: http://www.jbjs.org/Comments/2006/
cp_jan06_rimnac.shtml. Downloaded March 21, 2006.
Q
231
rachischisis
See SPINA BIFIDA.
rachitis See RICKETS.
radiculitis, radiculopathy With the words for
these inflammatory conditions sometimes used
interchangeably, problems begin when fluid leaks
from a small tear in an intervertebral
DISC or when
mechanical pressure in the
SPINE irritates the nerve
roots in that area. From such tiny points of origin,
spinal pain radiates into the arms, head, or legs.
To differentiate between radiculitis and radicu-
lopathy, online information from Nosuffering.com
said, “Radiculopathy is radiculitis caused by the
nerve root being compressed by a compressed ver-
tebral disk or arthritis. Radiculitis is characterized by
pain that seems to radiate from the spine to extend
outward to cause symptoms away from the source of
the spinal nerve root irritation. The term radiculitis is
used when symptoms demonstrate nerve root irrita-
tion but x-rays and other radiology show no abnor-
malities.” By contrast, a
HERNIATED DISC may bring a
definitive bulge that can be seen via X-
RAY or other
imaging tool.
Symptoms and Diagnostic Path
Sensitivity to touch sometimes characterizes radic-
ulitis, but patients usually experience either numb-
ness or the radiating pain of
SCIATICA. A medical
history and a physical examination that includes
the patient’s
RANGE OF MOTION may rule out other
conditions and help to provide a diagnosis. If soft
tissue and spinal nerves need to be evaluated, a
neurologist or other physician may request a
COM-
PUTED TOMOGRAPHY SCAN or MAGNETIC RESONANCE
IMAGING. More likely, those imaging tests will pri-
marily be used to determine a need for
SURGERY.
Treatment Options and Outlook
Treatment usually begins with
NONSTEROIDAL ANTI-
INFLAMMATORY DRUG (NSAID) THERAPY, physical
therapy, and rest. Other nonsurgical options include
COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)
therapies, such as
SPINAL MANIPULATION, or allo-
pathic options, such as
EPIDURAL INJECTION, INTRA-
DISCAL ELECTROTHERMAL THERAPY, SELECTIVE NERVE
ROOT BLOCK, and STEROID THERAPY. If left unchecked,
chronic inflammation can produce scarring around
the spinal nerves and evoke other problems, such
as
THORACIC OUTLET SYNDROME.
Risk Factors and Preventive Measures
People who experience a
FLEXION-EXTENSION INJURY,
such as a whiplash, have increased risk of acquir-
ing this condition. Also, patients with
ARTHRITIS,
SPINAL STENOSIS, DEGENERATIVE DISC DISEASE, or any
disc problem that causes the discs to leak and spi-
nal nerves to inflame may be at higher risk too.
Nevertheless, prompt treatment to lessen the dam-
aging effects of ongoing inflammation can lessen
the risks.
Medtronic Sofamor Danek. “Radiculopathy,” Back.com.
Available online. URL: http://www.back.com/symptoms-
radiculopathy.html. Last updated February 14, 2005.
Nosuffering.com. “Radiculitis / Radiculopathy.” Available
online. URL: http://www.nosuffering.com/nosuffering/
patient/symptoms/radio.shtml. Downloaded March 24,
2006.
Spinal Injury Foundation. “Chemical Radiculitis,” SIF. Avail-
able online. URL: http://www.spinalinjuryfoundation.
org/101_new/chemical.htm. Downloaded March 24,
2006.
radiofrequency treatment See FACET NEUROTOMY
OR FACET RHIZOTOMY INJECTION.
R
raloxifene See SELECTIVE ESTROGEN RECEPTOR MOD-
ULATORS (SERMS).
range of motion The natural flexibility of the SPINE
allows versatile movements as the head nods up
and down in an affirmative response or turns side
to side to negate. In the
THORACIC SPINE and LUMBAR
SPINE, the normal range of motion can produce a
catlike stretch or a backward arch. Shoulders shift
and rotate. Hips sway back and forth, and
POSTURE
can be held upright, assuming the facet joints and
DISCS between the VERTEBRAE remain intact and
retain their mobility.
The Back.com article “Dynamic Stabilization”
said, “Your spine is made up of 24 vertebrae and the
connection between each forms a joint, or ‘motion
segment’, with the vertebra above and the vertebra
below. These individual motion segments do not
provide the same range of motion as elbows and
knees, but they work together to allow for forward
and backward bending, side-to-side bending and
rotation. . . . Movement at a single motion segment
is limited to only a few degrees (focal motion), but
since motion segments are stacked on top of each
other, considerable movement is possible (global
motion). And, certain parts of the spine allow for
more movement than others. For instance, you
may have noticed that the bones in your neck pro-
vide more motion than those in your lower back.”
Risks and Complications
In the presence of
ACUTE PAIN, CHRONIC PAIN, and
inflammation, range of motion may decrease unless
therapeutic
EXERCISE or daily ACTIVITY encourage
movement. Often, muscle spasm,
SPRAIN, or STRAIN
limit flexibility in the
PARASPINAL MUSCLES, while a
FLEXION-EXTENSION INJURY (whiplash) inhibits nat-
ural movement of muscles in the
CERVICAL SPINE.
Conditions such as
ANKYLOSING SPONDYLITIS and
SURGERY involving SPINAL FUSION can limit range of
motion too. With a
SPINAL CORD injury, however,
patients cannot exercise spinal muscles and joints
without assistance from a therapist or caretaker.
Nevertheless, such movements remain necessary to
avoid pressure sores and keep the vertebral joints
mobile.
Statistics and Studies
Typically, medical technicians measure the range
of motion in the spine on a scale of 0 to 10, but
researchers from the Netherlands used a more
sophisticated approach to study the “Reproduc-
ibility of Cervical Range of Motion in Patients with
Neck Pain.” As reported in BMC Musculoskeletal Dis-
orders, “Neck pain is a common musculoskeletal dis-
order . . . and approximately one-third of all adults
will experience neck pain during the course of 1
year. Patients usually receive conservative treat-
ment such as physical therapy or continued care
by a General Practitioner (GP). A physical evalu-
ation is often used for both the diagnosis and the
evaluation of treatment success in patients with
neck pain. One aspect for the physical assessment
of the cervical spine is the evaluation of active
Range Of Motion (ROM).” Yet, “active cervical
ROM is difficult to measure because of compensa-
tory movements, and it is influenced by aging and
systemic disorders. Several non-invasive methods
for assessing the ROM have been available. . . . For
the majority of these instruments the . . . reproduc-
ibility has not been tested adequately. Radiography
has been proven to be of questionable reproducibil-
ity.” With a device referred to as the EDI-320 incli-
nometer, however, the results proved “acceptable,
despite slight variations.”
Special Aids and Adaptations
To assist patients in performing range of motion
exercises, The National Spinal Cord Injury Asso-
ciation (NSCIA) advised, “The exercises should be
performed in a smooth motion as quick motions
may cause damage to the joints. As the top of each
range is reached the position should be held for a
count of 10. During rehabilitation the team physi-
cal and occupational therapists will provide instruc-
tions on how to either perform or instruct others
on performing Range of Motion exercises that will
best meet your needs.” Besides focusing on spinal
areas with limited motion,
MASSAGE THERAPY may
ultimately aid the whole body. As the NSCIA said,
“If you were able to trace your nerves you would
find that almost every part of your body has a nerve
that ends in the foot. Massaging the sole of the foot
soothes these nerves and relieves pressure.”
232 raloxifene
Hoving, Jan Lucas, Jan J. M. Pool, Henk van Mameren,
Walter J. L. M. Devillé, Willem J. J. Assendelft, Hen-
rica C. W. de Vet, Andrea F. de Winter, Bart W. Koes,
and Lex M. Bouter. “Reproducibility of Cervical Range
of Motion in Patients with Neck Pain,” BMC Musculo-
skeletal Disorders 6, no. 59 (2005). Available online. URL:
http://www.biomedcentral.com/1471-2474/6/59.
Downloaded March 28, 2006.
Medtronic Sofamor Danek. “Dynamic Stabilization,”
Back.com. Available online. URL: http://www.back.
com/articles-motion_preservation.html. Last updated
January 5, 2006.
National Spinal Cord Injury Association, The. “Range of
Motion,” NSCIA. Available online. URL: http://www.
spinalcord.org/html/factsheets/range_of_motion.php.
Downloaded March 28, 2006.
reflex sympathetic dystrophy (RSD) syndrome
Also known as Complex Regional Pain Syndrome
(CRPS), this condition worsens rather than improves
over time. Increased levels of
CHRONIC BACK PAIN
can be particularly unfortunate for
ELDERLY patients
and young
CHILDREN or ADOLESCENTS perceived as
complaining to get attention. Instead, the opposite
may be true, as inexplicable but ongoing pain grabs
the attention of up to 1.2 million patients of all ages
in the United States alone. To make the condition
even more insidious, the initial provocation may be
as big as a bone
FRACTURE or as small as a splinter
in the thumb.
A fact sheet from the Reflex Sympathetic Dys-
trophy Syndrome Association (RSDSA) explained,
“RSD is a malfunction of part of the nervous sys-
tem. Nerves misfire, sending constant pain signals
to the brain. RSD develops in response to an event
the body regards as traumatic, such as an accident
or a medical procedure. This syndrome may follow
5% of all injuries.”
Symptoms and Diagnostic Path
Besides moderate to severe pain, RSD/CRPS symp-
toms characteristically include chronic inflam-
mation, muscle spasms, problems with
RANGE OF
MOTION, and changes in the nails or skin. Abnor-
malities in the sympathetic nervous system also
occur.
The online article “Clinical Practice Guidelines”
posted by the RSDSA explained, “For reasons we
do not understand, the sympathetic nervous sys-
tem seems to assume an abnormal function after
an injury. There is no single laboratory test to diag-
nose RSD/CRPS. Therefore, the physician must
assess and document both subjective complaints
(medical history) and, if present, objective findings
(physical examination), in order to support the
diagnosis. There is a natural tendency to rush to
the diagnosis of RSD/CRPS with minimal objective
findings because early diagnosis is critical. If undi-
agnosed and untreated, RSD/CRPS can spread to
all extremities, making the rehabilitation process a
much more difficult one. If diagnosed early, physi-
cians can use mobilization of the affected extremity
(physical therapy) and sympathetic nerve blocks to
cure or mitigate the disease.” The guidelines further
stated, “To make the early diagnosis of RSD/CRPS,
the practitioner must recognize that some features/
manifestations of RSD/CRPS are more characteris-
tic of the syndrome than others, and that the clini-
cal diagnosis is established by piecing each bit of the
puzzle together until a clear picture of the disorder
emerges. Often the physician needs to rule out other
potentially life-threatening disorders that may have
clinical features similar to RSD/CRPS, e.g. a blood
clot in a leg vein or a breast tumor spreading to
lymph glands can cause a swollen, painful extrem-
ity. Indeed, RSD/CRPS may be a component part of
another disease,” such as a
HERNIATED DISC.
Treatment Options and Outlook
According to a fact sheet from the National Insti-
tute of Neurological Disorders and Stroke, “the
prognosis for CRPS varies from person to person.
Spontaneous remission from symptoms occurs in
certain individuals. Others can have unremitting
pain and crippling, irreversible changes in spite of
treatment.”
To ease inflammation and discomfort, treatment
begins with
NONSTEROIDAL ANTI-INFLAMMATORY
DRUG THERAPY but can escalate to OPIATES or OPI-
OIDS FOR PAIN. Patients who need additional options
may want to investigate the relevant studies posted
by ClinicalTrials.gov. At this writing, for example,
RESEARCH has begun to assess various medications
reflex sympathetic dystrophy (RSD) syndrome 233
as well as such COMPLEMENTARY AND ALTERNATIVE
MEDICINE treatments as MAGNETIC THERAPY.
Risk Factors and Preventive Measures
Therapeutic
EXERCISE, such as swimming, and
HYDROTHERAPY may help to keep muscles flexible
and bones strong. Daily
ACTIVITY and healthful
NUTRITION can also be important in preventing mus-
cle wasting or the bone-thinning conditions, such
as
OSTEOPOROSIS, that sometimes accompany RSD.
If symptoms continue to worsen,
PAIN MANAGEMENT
may include
EPIDURAL INJECTION, NERVE BLOCK, OR
TRANSCUTANEOUS ELECTRONIC NERVE STIMULATOR
(TENS)
UNIT.
ClinicalTrials.gov. “Complex Regional Pain Syndrome,”
list of studies, National Institutes of Health. Available
online. URL: http://clinicaltrials.gov/search/term=Co
mplex%20Regional%20Pain%20Syndrome. Down-
loaded March 28, 2006.
National Institute of Neurological Disorders and Stroke.
“NINDS Complex Regional Pain Syndrome Informa-
tion Page,” National Institutes of Health. Available
online. URL: http://www.ninds.nih.gov/disorders/
reflex_sympathetic_dystrophy/reflex_sympathetic_
dystrophy.htm. Last updated March 17, 2006.
Reflex Sympathetic Dystrophy Syndrome Association.
“Clinical Practice Guidelines (Second Edition Updated
October 15, 2000) for the Diagnosis, Treatment, and
Management of Reflex Sympathetic Dystrophy Syn-
drome (RSD) also Known as Complex Regional Pain
Syndrome (CRPS),” RSDSA. Available online. URL:
http://www.rsds.org/3/clinical_guidelines/index.
html. Downloaded March 28, 2006.
———. “CRPS/RSD Fact Sheet,” RSDSA. Available online.
URL: http://www.rsds.org/2/fact_fiction/index.html.
Downloaded March 28, 2006.
research In the presence of CHRONIC PAIN, most
people want to know “Why?” or “What can be
done?” Such questions initiate research too. For
example, the research committee of the Orthopae-
dic Trauma Association (OTA) begins to consider
each potential research project by “identifying key
questions, recruiting lead investigators, organizing,
planning and potentially providing start-up funding
for these projects.” Typical, perhaps, of the process
involved in research, “the goal is to take advantage
of the substantial expertise and experience available
in the organization to advance our understanding
and to increase the quality of clinical research being
performed by the organization.”
Besides the many professional associations
devoted to spinal health and the
BACK, research
may begin within a single university or a group of
spine centers that pool their resources to investi-
gate a topic. Between 1998 and 2001, for example,
a team of physicians from the Hughston Clinic in
Columbus, Georgia, the Orthopedic Center of St.
Louis, and the Nebraska Spine Center in Omaha
studied the effectiveness of
BONE MORPHOGENETIC
PROTEIN (BMP) in promoting new bone growth in
131 patients requiring
ARTHRODESIS in the LUMBAR
SPINE. When they had accomplished their goal of
inserting BMP into the surgical sites instead of using
a
BONE GRAFT, the doctors reported their findings in
The Journal of Bone and Joint Surgery: “The patients in
the study group had significantly better outcomes
than the control group with regard to the average
length of surgery . . . , blood loss . . . , and hospital
stay.” In addition, “fusion rates were significantly
better in the study group.”
Other research projects emanate from pharma-
ceutical companies and government agencies. At
this writing, for example, the ClinicalTrials.gov
Web site sponsored by the National Institutes of
Health listed 26 clinical trials involving the
VERTE-
BRAE, 44 trials involving DISCS, and 103 focusing
on the
SPINE. Typically, research has a very specific
goal or premise. For instance, an initiative from the
National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) questioned the use of
important bone markers (BM) as a tool in studying,
diagnosing, and effectively treating such conditions
as
OSTEOARTHRITIS, OSTEOPOROSIS, and RHEUMATOID
ARTHRITIS. To clarify the rationale for such a study,
the NIAMS said, “BM are likely to be of value in
helping identify and classify genetically different
patients in clinical trials to ensure uniformity of
populations that can then be used to better define
change and responses to therapy in relationship to
clinical endpoints—such as rate of disease progres-
sion.” In other words, “BM offer opportunities to
more critically define the disease process” among
various types of individuals. By better understand-
234 research
ing the primary causes and answering relevant
questions that concern spinal conditions and their
progression, researchers may ultimately find more
workable solutions for the back and spine.
Risks and Complications
Ideally, research begins with perceptive questions,
but this carries an inherent risk of asking irrelevant
ones. Interesting findings can unexpectedly result
from a false start as new information surfaces, but
researchers prefer to avoid the complications of
misspending time, funding, and reputations.
Once a project has been staffed, funded, and
approved, the complicated process of screening
applicants begins. Even the most willing partici-
pants will be turned away if they do not meet the
criteria for a particular study, whereas those who
do qualify may find the schedule too demanding
to continue with the program. Also, some partici-
pants will not be selected to try a new medication
or treatment but may, instead, be given a placebo,
usually without their knowledge. Conversely,
patients who do have the opportunity to test a new
product or therapy may find the treatment does not
keep the condition from worsening. Also, the study
itself can encounter risks. If, for example, a patient
who receives an experimental drug drops out of the
study or dies, this obviously affects that person and
his or her family, but it can also hinder the research
and complicate results.
Statistics and Studies
Gene therapy often makes stimulating news, but to
stimulate the spine, research in this area has been
focusing on alternatives to
BONE MORPHOGENETIC
PROTEIN (BMP) to promote bone growth and speed
up spinal fusion. As an article from SpineUniverse
reported, “Since 1990, there have been over 300
human gene therapy trials with well over 3,000
patients enrolled, and this number is steadily
growing. For terminal systemic disorders such as
paralysis or Parkinson’s Disease, gene therapy has
had limited success; however for localized condi-
tions such as spinal fusion or disc regeneration,
gene therapy can be a very powerful and success-
ful tool.” For example, “instead of putting a protein
into the spine to stimulate fusion,” as occurs with
bone morphogenetic protein, “surgeons would
instead transfer the gene that codes for that protein
into a portion of the spinal tissues, allowing those
tissues to produce the protein responsible for bone
growth. Although this seems like a complex pro-
cedure, it is much less invasive than current spinal
fusion methods, which require an open incision, a
certain amount of blood loss, pain to the patient
and a significant period of healing. Gene therapy
has the ability to dramatically change how this sur-
gical procedure is performed.” As a practical exam-
ple and application, this type of gene therapy might
be used to repair a
SPINAL CORD injury or to treat a
disc problem.
The Human Genome Project Information, how-
ever, presented a less heartening view. After citing
previous setbacks to genetic research, information
from their Web site considered other factors, such
as procedures needed to handle DNA (deoxyri-
bonucleic acid) that carries each person’s genetic
information. According to the governmentally
sponsored genome project, “before gene therapy
can become a permanent cure for any condition,
the therapeutic DNA introduced into target cells
must remain functional and the cells containing
the therapeutic DNA must be long-lived and sta-
ble. Problems with integrating therapeutic DNA
into the genome and the rapidly dividing nature
of many cells prevent gene therapy from achieving
any long-term benefits.” Consequently, “patients
will have to undergo multiple rounds of gene ther-
apy.” In addition, “anytime a foreign object is intro-
duced into human tissues, the immune system is
designed to attack the invader. The risk of stimu-
lating the immune system in a way that reduces
gene therapy effectiveness is always a potential
risk. Furthermore, the immune system’s enhanced
response to invaders it has seen before makes it dif-
ficult for gene therapy to be repeated in patients.”
Although “conditions or disorders that arise from
mutations in a single gene are the best candidates
for gene therapy,”
GENETIC FACTORS may not be the
only concern. For example, ethical questions arise,
such as, “What is normal and what is a disability
or disorder, and who decides?” or, “Are disabilities
diseases? Do they need to be cured or prevented?”
and perhaps the trickiest question, “Does searching
for a cure demean the lives of individuals presently
affected by disabilities?”
research 235
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