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Journal of Medicine: “In an attempt to decrease sur-
gical morbidity, the microscope was employed in
conjunction with smaller incisions to minimize
postoperative trauma to the bone and soft tissue.”
Of the 500 patients who had been treated at that
writing, “most of the cases had a variety of symp-
tomatic disc protrusions, including . . . disc frag-
ments within reach. . . . With the ability to visualize
the spinal anatomy in a conscious patient comes the
opportunity to diagnose, evaluate, and treat painful
conditions.”
For most patients, this procedure brings an
improved outlook and the means of being sent home
with only a tiny bandage to show for the surgery.
During the recovery process, patients may need an
ice pack to minimize swelling and also
NONSTEROI-
DAL ANTI-INFLAMMATORY DRUG THERAPY to ease pain
and inflammation. Within a few days of the proce-
dure though, many patients can return to work.
Gross, Elliott, M.D. “Transforaminal Selective Endoscopic
Discectomy™: Recovery, Complications, Procedure and
Contraindications,” SpineUniverse. Available online.
URL: http://www.spineuniverse.com/displayarticle.php/
article1420.html. Last updated June 20, 2005.
Yeung, Anthony T., M.D. “The Evolution of Percutane-
ous Spinal Endoscopy and Discectomy,” The Mount
Sinai Journal of Medicine 67, no. 4 (September 2000):
327–332.
selective estrogen receptor modulators (SERMs)
As the name implies, this treatment modulates the
reception of estrogen in the body. The American
Medical Association (AMA) had this to say about
the SERM raloxifene: “Through its selective inter-
action with estrogen receptors, raloxifene exerts
estrogen agonist action in some target tissues,
while acting as an estrogen antagonist in others.”
With an agonist being for and antagonist against, a
SERM can go either way to take needed action. The
same principle applies to herbs classified as a tonic
in
HERBAL THERAPY. Nevertheless, herbals, such as
black cohosh and soy supplements, should not be
taken in conjunction with a SERM or other drug
used for a similar purpose.
In preventing
OSTEOPOROSIS in postmenopausal
women, raloxifene improves bone density without
causing breast tenderness or adding the concerns
about
CANCER that often accompany HORMONE
REPLACEMENT THERAPY (HRT). Indeed, the AMA
reported, “investigators found that there was a
decreased incidence of breast cancer in the women
who took raloxifene for 3 years.” Another SERM,
tamoxifen, primarily received approval to treat
breast cancer, whereas raloxifene was specifically
developed and approved to prevent osteoporosis in
older women.
Information from the breastcancer.org Web site
indicated that
CALCITONIN and BISPHOSPHONATES
reduce bone loss more than a SERM. Hormone
replacement therapy can too, but HRT increases
the risk of breast cancer. According to the Web
site, “If you’ve had breast cancer and you need a
medicine to build up your bone strength, your doc-
tor will likely recommend an alternative to HRT.
Bisphosphonates and SERMs are effective and safer
options.”
Dosage and Potential Side Effects
Under the brand name EVISTA, raloxifene can be
taken as a 60 mg tablet any time of day, with or
without food. As the drug manufacturer Eli Lilly
and Company advised, “To help you remember to
take EVISTA, it may be best to take it at about the
same time of the day. Calcium and/or vitamin D
may be taken at the same time as EVISTA. If you
miss a dose, take it as soon as you remember. How-
ever, if it is almost time for your next dose, skip
the missed dose and take only your next regularly
scheduled dose. Do not take two doses at the same
time.”
Pregnant women, smokers, and patients with
liver problems should not take a SERM. For women
in general, potential side effects include hot flashes
and blood clots. Since the latter can especially be a
problem for patients requiring bed rest or
SURGERY,
the use of a SERM should be discontinued at least
72 hours before a surgical procedure.
Statistics and Studies
According to the AMA Web site, raloxifene decreases
the incidence of
VERTEBRAL COMPRESSION FRACTURE
by 50 percent. Also, “vertebral fracture reduction
is evident at 1 year and is sustained for up to at
least 4 years in patients remaining on continuous
256 selective estrogen receptor modulators
therapy.” However, “when therapy is discontinued,
bone turnover returns to its previous state, result-
ing in bone loss.”
A study from the Czech Republic reported on
“The Effect of Raloxifene after Discontinuation of
Long-term Alendronate Treatment of Postmeno-
pausal Osteoporosis” in the Journal of Clinical Endo-
crinology and Metabolism. According to the abstract,
“the aim of this study was to compare bone min-
eral density (BMD) and biochemical markers of
bone turnover in patients receiving long-term
alendronate therapy who continued alendronate,
were switched to raloxifene, or discontinued anti-
resorptive therapy” that works with the body’s
natural bone remodeling cycle. After using
ALEN-
DRONATE for 43 months to treat 99 women diag-
nosed with osteoporosis, researchers found, “BMD
preservation and increase were most pronounced
in patients continuing alendronate.” However,
“raloxifene treatment, compared with placebo,
demonstrated beneficial effects on BMD and bone
turnover after discontinuation of long-term alen-
dronate therapy.” In addition to SERM therapy,
patients received daily supplements of
CALCIUM
and
VITAMIN D, both of which aid BONE BUILDING if
taken regularly.
American Medical Association. “Antiresorptive Therapy:
Selective Estrogen Receptor Modulators,” AMA. Avail-
able online. URL: http://www.ama-cmeonline.com/
osteo_mgmt/module05/05anti/index.htm. Downloaded
April 22, 2006.
breastcancer.org. “Other Bone Medications—SERMs.”
Available online. URL: http://www.breastcancer.org/
bone_serms.html. Downloaded April 22, 2006.
EVISTA.com. “Understanding EVISTA,” Eli Lilly and
Company. Available online. URL: http://www.evista.
com/understand_evista/understand_evista.jsp?req
NavId=1. Downloaded April 22, 2006.
Michalska, D., J. J. Stepan, B. R. Basson, and I. Pavo.
“The Effect of Raloxifene after Discontinuation of
Long-term Alendronate Treatment of Postmenopausal
Osteoporosis,” Journal of Clinical Endocrinology and
Metabolism 91, no. 3 (March 2006): 870–876.
selective nerve root block (SNRB) This type of
NERVE BLOCK does double duty: first, to locate the
source of nerve root pain and, second, to relieve
it. The procedure effectively treats patients with
CHRONIC BACK PAIN that has not been relieved
by conservative treatment. As a diagnostic tool,
SNRB offers more precision than
MAGNETIC RES-
ONANCE IMAGING in locating an inflamed spinal
nerve.
Procedure
Before the procedure, patients should avoid
PAIN
RELIEVERS and discuss other medications or con-
cerns with their doctors. For example, pregnant
women need to delay SNRB until a later time.
According to the Spine-health Web site, “in an
SNRB, the nerve is approached at the level where it
exits the foramen (the hole between the vertebral
bodies). The injection is done both with a steroid
(an anti-inflammatory medication) and lidocaine
(a numbing agent). Fluoroscopy (live x-ray) is used
to ensure the medication is delivered to the cor-
rect location. If the patient’s pain goes away after
the injection, it can be inferred that the back pain
generator is the specific nerve root that has just
been injected. Following the injection, the steroid
also helps reduce inflammation around the nerve
root.”
Risks and Complications
SNRB with
FLUOROSCOPY can be more complicated
to perform than, say, an
EPIDURAL INJECTION. There-
fore, patients do well to seek an experienced physi-
cian. Reportedly, SNRB carries no risk of springing
a leak in spinal fluids since the location of the
injection occurs outside the
SPINE. However, that
same locale houses spinal nerves that may be irri-
tated by the procedure, potentially increasing
LOW
BACK PAIN. Discomfort may increase for a couple of
days, but fever or
ACUTE PAIN should be reported
promptly.
An article in the Archives of Physical Medicine and
Rehabilitation reviewed specific “complications and
side effects of cervical and lumbosacral selective
nerve root injections.” At a
SPINE clinic in Arizona,
151 patients had 306 selective nerve root injec-
tions (SNRI) with follow-ups immediately, then
at 1 week and 3 months. According to the study,
“there were no major complications, such as death,
paralysis, spinal nerve injury, infection, or allergic
selective nerve root block 257
reaction, during the study. Ninety-one percent of
subjects had no side effects during the procedure.”
Patients who received treatment for locations
occurring between the
LUMBAR SPINE and SACRAL
VERTEBRAE experienced an increase in radicular or
radiant nerve pain, such as occurs in
SCIATICA. Spe-
cifically, their side effects included “increased pain
at the injection site (17.1%); increased radicular
pain (8.8%); lightheadedness (6.5%); increased
spine pain (5.1%); nausea (3.7%); nonspecific
headache (1.4%); and vomiting (0.5%).” Patients
who received treatments for the
CERVICAL SPINE
experienced side effects of “increased pain at injec-
tion site (22.7%); increased radicular pain (18.2%);
lightheadedness (13.6%); increased spine pain
(9.1%); nonspecific headache (4.5%); and nausea
(3.4%).”
Outlook and Lifestyle Modifi cations
After SNRB, an ice pack applied four times a day
for about ten minutes may relieve pain and swell-
ing. For patients who can take
ACETAMINOPHEN, a
minimal dose may ease discomfort. To avoid risk of
bleeding, a
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
(NSAID), such as
ASPIRIN, should not be taken for at
least 36 hours after the procedure.
If needed, SNRB can be repeated up to three
times a year. However, patients who experience
pain relief do well to increase their daily
ACTIVITY,
begin a doctor-approved program of
EXERCISE, and
increase their
WATER intake. Similarly, supportive
NUTRITION assists spinal health for years to come.
Huston, C. W., C. W. Slipman, and C. Garvin. “Compli-
cations and Side Effects of Cervical and Lumbosacral
Selective Nerve Root Injections,” Archives of Physical
Medicine and Rehabilitation 86, no. 2 (February 2005):
277–283.
International Spine Intervention Society, Patient Informa-
tion. “Selective Nerve Root Block,” SpineUniverse.
Available online. URL: http://www.spineuniverse.com/
displayarticle.php/article346.html. Last updated Novem-
ber 16, 2005.
Spine-health.com. “Injections for Back Pain Management.”
Available online. URL: http://www.spine-health.com/
topics/conserv/overview/inj/inj03.html. Downloaded
April 8, 2006.
Stanford Interventional Spine Center. “Patient Informa-
tion and Instructions Following Spinal Injections,”
Stanford University School of Medicine. Available
online. URL: http://isc.stanford.edu/postprocedures_
inject.html. Last modified May 25, 2005.
shaken baby syndrome, shaken infant syndrome
Similar to a whiplash, this type of
FLEXION-EXTENSION
INJURY occurs in a flash as the head snaps forward,
then back, damaging the
CERVICAL SPINE. In explain-
ing what happens, information from the National
Center on Shaken Baby Syndrome said, “The brain
rotates within the skull cavity, injuring or destroy-
ing brain tissue. When shaking occurs, blood vessels
feeding the brain can be torn, leading to bleeding
around the brain. Blood pools within the skull,
sometimes creating more pressure within the skull
and possibly causing additional brain damage. Reti-
nal (back of the eye) bleeding is very common.”
Symptoms and Diagnostic Path
Severe cases involve neurological damage and often
death. At first, the
INFANT becomes unconscious as the
central nervous system shuts down, but immediate
medical treatment may prevent death or permanent
disability. If the child survives, the injuries typically
include
FRACTURE to the CERVICAL SPINE, damaged
VERTEBRAE, and a SPINAL CORD injury that may pro-
duce retardation or other neurological symptoms.
Regarding signs of a less severe episode, the
National Institute of Neurological Disorders and
Stroke (NINDS) said, “Symptoms of shaken baby
syndrome include extreme irritability, lethargy,
poor feeding, breathing problems, convulsions,
vomiting, and pale or bluish skin. Shaken baby
injuries usually occur in children younger than 2
years old, but may be seen in children up to the
age of 5.”
Often, the condition goes unrecognized. In an
article for the National Center on Shaken Baby Syn-
drome, Dr. Carole Jenney wrote, “Not surprisingly,
the severely injured children were more likely to be
recognized as having head trauma at their first visit
to the physician. At the first visit, children who were
comatose, whose breathing was compromised, who
were seizing or who had facial bruising were more
likely to be accurately diagnosed.” Especially among
258 shaken baby syndrome, shaken infant syndrome
babies and young CHILDREN, “non-specific signs such
as vomiting, fever and irritability are frequently seen
in a myriad of conditions, including many minor ill-
nesses. The difficulty, then, is to be able to tell when
these signs and symptoms occurred because of serious
head injuries.” Early detection is crucial. However,
“abusive head trauma was missed significantly more
often in children who were Caucasian than in chil-
dren of minority races, and was more likely missed in
families where both parents lived with the child.”
Treatment Options and Outlook
Emergency treatments include such life-sustain-
ing efforts as respiratory support and sometimes
SURGERY to stop internal bleeding. As the NINDS
said, “In comparison with accidental traumatic
brain injury in infants, shaken baby injuries have
a much worse prognosis. Damage to the retina of
the eye can cause blindness. The majority of infants
who survive severe shaking will have some form
of neurological or mental disability, such as cere-
bral palsy or mental retardation, which may not
be fully apparent before 6 years of age. Children
with shaken baby syndrome may require lifelong
medical care.” To evaluate the damage and estab-
lish a prognosis,
MAGNETIC RESONANCE IMAGING and
a
LUMBAR PUNCTURE will usually be required.
Risk Factors and Preventive Measures
An article in the May 2005 issue of RN discussed
the results of a “simple educational program”
tested in 16 hospitals that provide maternity care.
“Nurses spoke to parents about the dangers of vio-
lently shaking their infant, gave them a one-page
brochure, and suggested ways to manage persistent
crying. Some parents also viewed a short video.”
After asking parents to sign a statement showing
their understanding and commitment, “Researchers
obtained . . . signed statements, which represented
about 70% of all births in the region during the
study period.” Six years prior to the study, “there
were 49 cases of shaken baby syndrome in the eight
counties, or about 41.5 per 100,000 births. During
the 5.5-year study, there were 21 cases, or about
22.2 per 100,000 births. This represented a statisti-
cally significant 47% reduction.”
The American Association of Neurological Sur-
geons also offered this potentially life-saving word:
“Shaken baby syndrome is completely preventable.
Taking care of a baby can present challenges, espe-
cially for first-time parents. However, it is impor-
tant to remember that it’s never acceptable to
shake, throw, or hit a baby. The following tips may
help prevent abuse: Take a deep breath and count
to 10. Take time out and let your baby cry alone.
Call someone close to you for emotional support.
Call your pediatrician—there may be a medical rea-
son why your baby is crying. Never leave your baby
with a caregiver, friend, or family member that you
do not trust completely. Always check references
carefully before entrusting your baby to a caregiver
or daycare center.”
Understanding the needs of a baby or young
child can ease worries that most new parents
experience. Also, the importance of adequate
NUTRITION and ample SLEEP for caretakers can not
be overstressed. Only a few sleepless nights alters
body chemistry, turning a normally patient, loving
person into someone with symptoms of psycho-
sis. If support from relatives or friends cannot be
found, a parent does well to nap whenever the
baby does until restorative rest becomes a family
routine.
Bauer, Jeff. “This Nursing Intervention Can Help Pre-
vent Shaken Baby Syndrome,” RN 68, no. 5 (May
2005): 22.
Jenney, Carole, M.D. “Abusive Head Trauma Can Be Dif-
ficult for Physicians to Recognize,” National Center
on Shaken Baby Syndrome. Available online. URL:
http://www.dontshake.com/Subject.aspx?categoryID
=12&PageName=MedicalFactsDiagnoseTrauma.htm.
Downloaded April 22, 2006.
National Center on Shaken Baby Syndrome. “All About
SBS.” Available online. URL: http://www.dontshake.
com/Subject.aspx?CategoryID=12. Downloaded April
22, 2006.
National Institute of Neurological Disorders and Stroke.
“NINDS Shaken Baby Syndrome Information Page,”
NINDS. Available online. URL: http://www.ninds.
nih.gov/disorders/shakenbaby/shakenbaby.htm. Last
updated January 25, 2006.
NeurosurgeryToday.org. “Shaken Baby Syndrome,” Amer-
ican Association of Neurological Surgeons. Available
online. URL: http://www.neurosurgerytoday.org/what/
patient_e/shaken.asp. Downloaded April 22, 2006.
shaken baby syndrome, shaken infant syndrome 259
shoe choice, spinal effects of A well-designed
shoe not only aids foot motion but helps
POSTURE
and assists balance in the
SPINE. If feet squeeze into
too-tight attire, the legs and
BACK feel that TENSION.
If high heels spike the heel of each foot, natural
spinal curvatures curve unnaturally to compensate.
If the arch of a shoe does not fit the arch of a foot,
SACRAL VERTEBRAE encounter arching pain. If the
shoe soles do not stand solely for safety and com-
fort, intervertebral
DISCS receive a soulful slap with
each step.
A commercial Web site for Asics America
explained normal interactions that occur between
body planes and foot motion: “The Sagittal Plane
divides the body into left and right halves. The
foot motion within this plane is dorsiflexion and
plantarflexion.” In other words, an imaginary line,
drawn from head to toe, shows if the feet go up
and down or drag on the ground. Somewhere
around the waistline, “the Transverse Plane divides
the body into upper and lower halves. The foot
motion within this plane is adduction and abduc-
tion,” which shows if toes turn out or in. Finally,
“the Frontal Plane divides the body into front and
back halves. The foot motion within this plane is
inversion and eversion,” which shows if feet tilt
toward or away from the body, causing a potential
SPRAIN or heel pain either way. Ideally though, a
well-designed shoe enables each foot to take a turn
contacting the ground, pushing off, going airborne,
then returning to the first position. These motions
may occur in a fast run, a brisk jog, or a snail-paced
walk, but regardless, a fitting shoe helps to ensure
the ongoing feat of mobility.
Risks and Complications
Since
CHILDREN and young ADOLESCENTS outgrow
their shoes quickly, they have increased risks
of an improper fit that contributes to musculo-
skeletal problems. In addressing other concerns,
the American Orthopaedic Foot & Ankle Society
(AOFAS) said, “Children’s feet perspire greatly,
and the upper part of their shoes should be made
of breathable materials. Leather or canvas allows
the foot to breathe. Avoid man made material, such
as plastic.” Also, “make sure the insole is made of
absorbent material. You may want padded insoles.
Most children do not need a special arch support.
All toddlers younger than 16 months have flat feet
and only fully develop an arch by the age of 6 to
8 years.” Poor designs also increase the risks of
falls. For instance, “the outer sole provides traction,
cushioning, and flexibility to the shoe. Some very
sticky and thick outer soles can make young chil-
dren clumsy and cause falls and should be avoided.”
The same can be said about appropriate footwear
for
ELDERLY persons or anyone with a stability prob-
lem. For toddlers, “flat outer soles make it easier to
begin walking. Older children can wear shoes with
heels, but they should not be too high (bigger than
one inch) as this can cause the foot to slide forward,
cramping the toes against the shoe.”
In the online article “Shoes,” the American
Academy of Orthopaedic Surgeons (AAOS) offered
suggestions that may help
ATHLETES to lessen the
risk of choosing the wrong type of footwear. As the
AAOS explained, “The purpose of athletic shoes is
to protect the feet from the specific stresses encoun-
tered in a given sport and to give the player more
traction. A jogging shoe will be designed differently
from an aerobics shoe, for example. The differences
in design and variations in material, weight, lac-
ing characteristics and other factors among athletic
shoes are meant to protect the areas of the feet that
encounter the most stress.”
To lessen risks of injuries among outdoor work-
ers, the AAOS advised, “Work shoes are also avail-
able with varying characteristics, depending on the
wearer’s occupation. Boots made of thick leather
with steel toe boxes can be worn to protect the feet
from injury. Boots with varying degrees of traction
also are available.” For women who work indoors,
the AAOS cautioned, “High-heeled, pointed-toe
shoes can cause numerous orthopaedic problems,
leading to discomfort or injury to the toes, ankles,
knees, calves and back. Most high-heeled shoes
have a pointed, narrow toe box that crowds the
toes and forces them into an unnatural triangular
shape. These shoes distribute the body’s weight
unevenly, placing excess stress on the ball of the foot
and on the forefoot.” However, “even low-heeled
shoes can cause problems if they don’t fit well.
Years of wearing too-small shoes can lead to per-
manent deformities.” To avoid complications from
wearing ill-fitting footwear, the AAOS suggested:
“Have your feet measured regularly. Their size may
260 shoe choice, spinal effects of
change as you grow older. . . . Don’t select a shoe
by size alone. A size 10 in one brand or style may
be smaller or larger than the same size in another
brand or style. Buy the shoe that fits well.”
Statistics and Studies
In an article entitled “If the Shoe Fits, Wear It,” the
AAOS reported, “One in six persons or 43.1 mil-
lion people in the U.S. have foot problems. Thirty-
six percent regard their foot problems as serious
enough to warrant medical attention.” Although
well-made shoes may seem expensive, “the cost of
foot surgery to correct foot problems from tight-
fitting shoes is $2 billion a year. If time off from
work for the surgery and recovery is included, the
cost is $3.5 billion.”
In an unexpected twist, an AOFAS press release
announced, “A recent . . . online survey of over
1,200 runners found that almost two thirds had
injuries that they related to their shoes; however,
these injuries did not appear to be linked to how
much the runners paid for their shoes or whether
or not they used an inserted Orthotic device.”
Interestingly though, “there was no significant dif-
ference in incidence of injury between those paying
$20 for shoes or those who paid $120.” According
to the survey, the fit of a shoe carries more weight
than the price. Also, the age of a shoe has a bear-
ing on safety. Not only does an older shoe provide
the proverbial old shoe comfort, but runners appar-
ently feel more sure-footed too. As the AOFAS said,
“All injury types occurred predominantly in shoes
less than six months old and in shoes in which the
respondents had run less than 300 miles,” suggest-
ing that injuries most often occur during the break-
in period.
Special Aids and Adaptations
An article in BioMechanics discussed how various
“In-shoe Interventions Ease Back Pain through
Postural Correction.” For instance, “heel lifts can
correct the amount of pelvic obliquity” or tilt as
“determined from the postural radiographs. In our
clinics we usually correct the discrepancy in
1
⁄
8
-inch
increments every 10 to 14 days through the use of
cork heel lifts. A lift of as much as ½ inch will fit
comfortably in most shoes. For correction over ½
inch, the amount of lift needs to be added to the
outsole of the shoe. We counsel patients that the
added lift may increase pain for a few days as the
body adjusts to the changes. A follow-up postural
radiograph may be done with the lift in place once
the goal height has been achieved or if there is a sig-
nificant increase in symptoms while the lift height
is being increased.”
Once an
ORTHOTIC has been adjusted, the Amer-
ican Academy of Podiatric Sports Medicine recom-
mended, “If you wear an insert, an orthotic, or
an orthotic with a flat insert underneath it, bring
these along to the shoe store. And be sure to wear
the same type of sock when you are fitted for your
shoe as you will wear when participating in your
sport.” Regardless of the level of daily
ACTIVITY
or the age of the person, shoes must adapt to the
individual, not the other way around. This may
not be easy since one foot will usually be larger
than the other. If so, the larger size should be pur-
chased with an insert added to accommodate the
smaller foot.
Different manufacturers create different designs,
but in general, the toe box of the shoe should allow
wiggle room. The heel should be snug without rais-
ing a blister, and the inner and outer edges or last of
the shoe should follow the contour of the foot. No
shoe lasts forever, though. As the American Acad-
emy of Podiatric Sports Medicine advised, “Make
sure you examine and replace your shoes regularly.
Most running shoes last for between 350 miles and
500 miles of running. Checking and changing your
shoes is one of the best ways to avoid the doctor’s
office. With a careful training schedule that avoids
over training and doing too much, too soon, too
quickly and too often, you can reduce your risk . . .
markedly. Be sure to check all aspects of your shoe
for wear.”
American Academy of Orthopaedic Surgeons. “If the
Shoe Fits, Wear It,” AAOS. Available online. URL:
http://orthoinfo.aaos.org/fact/thr_report.cfm?thread_
id=104&topcategory=foot. Downloaded April 25,
2006.
———. “Shoes,” AAOS. Available online. URL: http://
orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_
ID=15&topcategory=Foot. Downloaded April 25, 2006.
American Academy of Podiatric Sports Medicine. “Select-
ing An Athletic Shoe.” Available online. URL: http://
shoe choice, spinal effects of 261
www.aapsm.org/fit_shoes.htm. Downloaded April 25,
2006.
American Orthopaedic Foot & Ankle Society. “A Guide
To Children’s Shoes,” AOFAS. Available online. URL:
http://www.aofas.org/i4a/pages/index.cfm?pageid=
3290. Downloaded April 25, 2006.
———. “Survey Shows Runners Commonly Experi-
ence Shoe Related Injuries: Cost of Shoes Bears Little
Relationship to These Injuries,” AOFAS. Available
online. URL: http://www.aofas.org/i4a/pages/index.
cfm?pageid=3284. Downloaded April 25, 2006.
Asics America Corporation. “Cardinal Body Planes.”
Available online. URL: http://www.asicsamerica.com/
asicstech/cardinal_body_planes.htm. Downloaded April
25, 2006.
Fann, Alice V., M.D. “In-shoe Interventions Ease Back Pain
through Postural Correction,” BioMechanics May 2001,
CMP United Business Media. Available online. URL: http://
www.biomech.com/db_area/archives/2001/0105.foot
ortho.bio.shtml. Downloaded April 25, 2006.
skeletal dysplasia Sometimes mild, sometimes
life-threatening, this group of disorders includes
about 200 conditions, such as
DWARFISM, OSTEO-
GENESIS IMPERFECTA, and some BIRTH DEFECTS OF THE
SPINE. Very mild cases may become noticeable in
ADOLESCENTS or adults, but most of these disorders
become apparent in
INFANTS and young CHILDREN.
Although causes remain unclear, skeletal dysplasia
may result from poor
NUTRITION, adverse ENVIRON-
MENTAL INFLUENCES, or, more commonly, GENETIC
FACTORS involving a gene that affects the formation
or quality of cartilage. Ultimately, the defective car-
tilage alters the shape and strength of spinal joints
as well as the development of the
BACK, SPINE, and
other bones.
The Human Genome in London, England,
explained, “The body’s scaffolding—the skeleton—
grows at a remarkable rate as we transform from a
tiny baby into a full-sized adult. Whether we are
destined to be tall or short the process is the same:
for about 15 years, our bones will lengthen and
harden until we reach our full height. Like all tis-
sues of the body, however, bones can be stricken
by genetic disease. About one in 4,000 people suf-
fer from skeletal dysplasias, genetic disorders of the
skeleton such as brittle bone disease (osteogenesis
imperfecta) or dwarfism.”
Symptoms and Diagnostic Path
X-
RAYS and other imaging tools, such as a COMPUTED
TOMOGRAPHY SCAN or MAGNETIC RESONANCE IMAG-
ING, will usually be needed to assess bones, joints,
and neurological problems such as those caused by
compression of the
SPINAL CORD. Most patients also
exhibit mild to severe
POSTURE problems, such as
SCOLIOSIS and KYPHOSIS.
In discussing one type of dysplasia, the Green-
berg Center for Skeletal Dysplasias at Johns Hop-
kins said, “Orthopedic problems are common. The
joints can be dislocated, especially the shoulder,
elbows, hips, and patellae (knee caps). Flexion
contractures of knees and shoulders are common.
Scoliosis is not present at birth but often is progres-
sive, especially in the early teens. Treatment of the
scoliosis includes bracing and occasionally, spinal
fusion. Progressive cervical kyphosis can also occur
with subluxation of the cervical spine which can
result in spinal cord compression.”
Treatment Options and Outlook
Skeletal dysplasia frequently produces early onset
of
OSTEOARTHRITIS, but early treatment may lessen
the severity. During formative bone growth,
ORTHOTIC devices may help to prevent the progres-
sion of curvatures. If a skeletal deformity occurs, a
LUMBAR LAMINECTOMY or other type of SURGERY may
be needed.
Risk Factors and Preventive Measures
To assess the risk of skeletal dysplasia, genetic
counseling includes a prenatal diagnosis during the
second trimester of pregnancy. As parents consider
their choices, one option includes participation in
RESEARCH or CLINICAL TRIALS. In their “Research on
Skeletal Dysplasias,” for example, the European
Skeletal Dysplasia Network has found “identify-
ing groups of proteins associated with specific . . .
structures or pathways, and how such patterns are
perturbed as a result of pathological changes.” Such
findings may eventually produce preventives that
address and, perhaps, even correct this group of
disorders before skeletal defects occur.
262 skeletal dysplasia
European Skeletal Dysplasia Network. “Research on Skel-
etal Dysplasias.” Available online. URL: http://www.
esdn.org/research.html. Downloaded April 26, 2006.
Greenberg Center for Skeletal Dysplasias. “Diastrophic
Dysplasia,” Johns Hopkins Hospital Center for Med-
ical Genetics. Available online. URL: http://www.
hopkinsmedicine.org/greenbergcenter/diastrop.htm.
Downloaded April 26, 2006.
Human Genome, The. “Growing Pains: Investigating Skel-
eton Disorders,” Wellcome Trust. Available online. URL:
http://genome.wellcome.ac.uk/doc%5Fwtd020828.
html. Downloaded April 26, 2006.
skeletal fluorosis Caused by ENVIRONMENTAL
INFLUENCES, this rare condition can result in skeletal
deformities. According to the U.S. National Library
of Medicine, “Skeletal fluorosis was first recognized
in 1931 among workers processing cryolite,” a natu-
ral fluoride but also a manufactured ingredient that
occurs during the production of aluminum. With
extended exposure, “patients may develop bony
exostoses,” or bony growths on the exterior surface
of a bone, as well as “calcified ligaments, kyphosis,
and spinal stenosis. Crippling skeletal fluorosis has
been reported in workers with fluoride exposures
of 20–80 mg/day for 10–20 years.”
Symptoms and Diagnostic Path
In the online article entitled “Skeletal Fluorosis,”
GreenFacts.org said, “The early stages of skeletal
fluorosis are characterized by increased bone mass,
detectable by x-ray. If very high fluoride intake per-
sists over many years, joint pain and stiffness may
result from the skeletal changes.”
Besides a patient history and physical exami-
nation, X-
RAYS can monitor the resultant muscu-
loskeletal conditions, such as
KYPHOSIS or SPINAL
STENOSIS. If symptoms include muscle wasting or
indicate a neurological problem caused by
SPI-
NAL CORD compression, additional tests will be
needed.
Treatment Options and Outlook
For the best treatment and outlook, an online arti-
cle by Doctors D. Raja Reddy and Srikanth R. Deme
advised, “In all cases of skeletal fluorosis prevention
is the aim, since no cure is possible through medi-
cal or surgical therapy, especially if it is allowed to
develop to the stage when it becomes a crippling
disease.” Besides safe sources of
WATER, “The plane
of nutrition appears to play a crucial role in the
incidence and severity of fluorosis and hence a bal-
anced diet having adequate calcium and vitamins
reduces the toxicity of fluoride.”
Risk Factors and Preventive Measures
The article “Scientific Facts on Fluoride” posted by
GreenFacts.org said, “In areas of the world with
high levels of fluoride naturally present in min-
erals and water, intake of fluoride from drink-
ing water and foodstuffs is the primary cause for
endemic skeletal fluorosis, a crippling disability
that affects millions of people in various parts
of Africa, China and India. In some regions, the
indoor burning of fluoride-rich coal also serves as
an important source of fluoride.” In the United
States, “When drinking water is artificially fluori-
dated, the ‘optimum’ level of fluoride, associated
with the maximum level of dental caries protec-
tion and minimum level of dental fluorosis, is
considered to be approximately 1 mg/litre.” Den-
tal products increase potential intake, but such
amounts remain minimal. However, “at total
fluoride intakes of 14 mg/day, there is clear evi-
dence of skeletal fluorosis and an increased risk of
bone fractures; at total intake levels above about
6 mg fluoride/day the evidence is suggestive of an
increased risk of effects on bone.” Therefore, the
best preventive comes in being aware of individual
intake, prolonged exposure, and personal sensi-
tivities. Healthful
NUTRITION emphasizing CALCIUM
and the nutrients in fresh fruits and vegetables can
also detoxify the body.
GreenFacts.org. “Scientific Facts on Fluoride,” Green-
Facts™. Available online. URL: http://www.greenfacts.
org/fluoride/fluorides-2/99-conclusion.htm#0. Down-
loaded April 26, 2006.
———. “Skeletal Fluorosis,” GreenFacts™. Available on-
line. URL: http://www.greenfacts.org/glossary/pqrs/
skeletal-fluorosis.htm. Downloaded April 26, 2006.
Reddy, D. Raja and Srikanth R. Deme. “Skeletal Fluoro-
sis.” Available online. URL: http://www.medvarsity.
com/vmu1.2/dmr/dmrdata/cme/fluorosis/Fluorosis.
htm. Downloaded April 26, 2006.
skeletal fluorosis 263
U.S. National Library of Medicine. “Skeletal Fluorosis,”
Haz-Map, National Institutes of Health. Avail able on-
line. URL: http://hazmap.nlm.nih.gov/cgi-bin/hazmap_
generic?tbl=TblDiseases&id=247. Last updated July 20,
2004.
sleep As a most basic need, rest restores. Restful
sleep detoxifies the body, repairs cells, and builds
bone tissue, especially when assisted by life-giving
NUTRITION and vital amounts of WATER. Adequate
rest keeps the mind alert, yet just a night or two
of sleep deprivation makes a person physically and
mentally unstable. Whether in the form of a cat-
nap or deep rest, each stage of sleep has some mea-
sure of recuperative power.
The National Institute of Neurological Disorders
and Stroke (NINDS) further explained, “Deep sleep
coincides with the release of growth hormone in
children and young adults. Many of the body’s cells
also show increased production and reduced break-
down of proteins during deep sleep. Since proteins
are the building blocks needed for cell growth and
for repair of damage from factors like stress and
ultraviolet rays, deep sleep may truly be ‘beauty
sleep’.” Since sleep requirements change over time,
“the amount of sleep each person needs depends
on many factors, including age. Infants generally
require about 16 hours a day, while teenagers need
about 9 hours on average. For most adults, 7 to 8
hours a night appears to be the best amount of sleep,
although some people may need as few as 5 hours
or as many as 10 hours of sleep each day. Women
in the first 3 months of pregnancy often need sev-
eral more hours of sleep than usual. The amount of
sleep a person needs also increases if he or she has
been deprived of sleep in previous days. Getting too
little sleep creates a ‘sleep debt,’ which is much like
being overdrawn at a bank. Eventually, your body
will demand that the debt be repaid.”
Risks and Complications
Patients in pain have a greater risk of developing
sleep problems. Likewise, patients who have trou-
ble sleeping have an increased risk of pain. As the
National Sleep Foundation reported, “a recent study
found that about two-thirds of patients with chronic
back pain suffered sleep trouble. This same study
suggests that disrupted sleep seems to make the pain
feel worse. Some pain medication, such as analgesics,
may alter sleep patterns and make sleeping more dif-
ficult.” Alcohol, nicotine, caffeine, antidepressants,
and emotional encounters at bedtime increase the
likelihood of insomnia, but then
ACUTE PAIN, CHRONIC
BACK PAIN, BACKACHES, CERVICOGENIC HEADACHES, and
LOW BACK PAIN can keep anyone awake.
Statistics and Studies
A study of the effects of
ACUPUNCTURE on pain and
sleep in Medical Acupuncture: A Journal for Physicians
By Physicians reported the following results: “Among
the 11 patients with low back pain (including 3 with
failed back syndrome), 36% (4), 36% (4), and 9%
(1) reported significant, moderate, and mild degrees
of pain relief, respectively. Nine percent (1), 36.3%
(4), and 36.3% (4) reported significant, moderate,
and mild degrees of sleep improvement, respec-
tively. In addition, 9% (1), 64% (7), and 9% (1)
of patients with low back pain reported significant,
moderate, and mild degrees of a sense of improve-
ment in well-being with acupuncture treatment.”
Regarding the
CERVICAL SPINE, “eight patients with
chronic neck pain were treated with acupuncture.
Seven demonstrated pain relief with acupuncture:
37.5% (3), 37.5% (3), and 12.5% (1) showed sig-
nificant, moderate, and mild degrees of pain relief,
respectively. Five reported sleep improvement:
37.5% (3) and 25% (2) showed a significant and
moderate degree of improvement, respectively.”
At the National Institutes of Health (NIH), some
studies of sleep aids focused on valerian, a form
of
HERBAL THERAPY. Subsequently, the NIH Office
of Dietary Supplements reported, “Although the
results of some studies suggest that valerian may be
useful for insomnia and other sleep disorders, results
of other studies do not. Interpretation of these stud-
ies is complicated by the fact the studies had small
sample sizes, used different amounts and sources of
valerian, measured different outcomes, or did not
consider potential bias resulting from high partici-
pant withdrawal rates. Overall, the evidence from
these trials for the sleep-promoting effects of valerian
is inconclusive.” Despite a lack of scientific proof, the
NIH also said, “Valerian has been used as a medicinal
herb since at least the time of ancient Greece and
Rome. Its therapeutic uses were described by Hip-
264 sleep
pocrates, and in the 2nd century, Galen prescribed
valerian for insomnia.” While this ancient treatment
may not help some patients, others find the herb
relaxing, assuming, of course, that its wet-dog or
sweaty-sock smell does not keep a person awake.
Special Aids and Adaptations
As ads often attest, restful sleep begins with a good
mattress. This does not refer to price so much as to
whether the coils, air, water, or foam cushioning
can hold the
SPINE in a neutral position. Similarly,
pillows should be chosen to keep the neck neutral,
so the head tilts neither up nor down. People who
sleep on the side often do well with a firm pillow,
while
BACK sleepers may prefer a medium one.
Although stomach sleeping can produce
NECK PAIN,
this may be avoidable with a down-soft pillow that
lays almost flat.
If a comfortable environment does not have the
desired effect, comforting forms of
MASSAGE THER-
APY may sooth INFANTS, CHILDREN, and ELDERLY per-
sons who resist sleep or just have trouble relaxing.
For active
ADOLESCENTS and adults, daily ACTIVITY
or
EXERCISE may start a day off right, but evening
exercises seldom end well in sleep. H
OMEOPATHIC
MEDICINE or other temporary sleep aids may help,
but adapting a routine conducive to rest provides
a better option. For example, poor sleepers might
practice techniques to reduce
TENSION then wait
until a half hour or so before bedtime to take a
CAL-
CIUM supplement and a warm bath. For patients
with chronic back or joint pain, a
PAIN RELIEVER an
hour or two before bedtime may ease discomfort in
time to catch sight of a few sweet dreams.
Goldberg, Joan Rachel. “Helping Yourself to a Good Night’s
Sleep,” National Sleep Foundation. Available online. URL:
http://www.sleepfoundation.org/sleeplibrary/index.
php?secid=&id=55. Downloaded April 26, 2006.
Leung, Albert Y., M.D. “Effect of Acupuncture on the Qual-
ity of Life in Patients with Chronic Pain: A Prospective
Outcome Measure,” Medical Acupuncture: A Journal for
Physicians By Physicians 14, no. 2. Available online. URL:
http://www.medicalacupuncture.org/aama_marf/
journal/vol14_2/article7.html. Downloaded April 26,
2006.
National Institute of Neurological Disorders and Stroke.
“Brain Basics: Understanding Sleep,” NINDS, National
Institutes of Health. Available online. URL: http://
www.ninds.nih.gov/disorders/sleep_apnea/detail_
sleep_apnea.htm. Last updated January 25, 2006.
National Sleep Foundation. “Pain and Sleep,” Sleep
Library. Available online. URL: http://www.sleep-
foundation.org/sleeplibrary/index.php?secid=&id=63.
Downloaded April 26, 2006.
Office of Dietary Supplements. “Questions and Answers
About Valerian for Insomnia and Other Sleep Disorders,”
National Institutes of Health. Available online. URL:
http://ods.od.nih.gov/factsheets/valerian.asp. Down-
loaded April 26, 2006.
slipped disc See HERNIATED DISC.
spina bifida A BIRTH DEFECT OF THE SPINE, spina
bifida is often obvious in
INFANTS born with an open-
ing in the
BACK where none should be. Although
spina bifida means cleft spine, not all forms of the
disorder may be readily apparent. In explaining the
contributive conditions, the Centers for Disease
Control and Prevention said, “Neural tube defects
(NTDs) are major birth defects of a baby’s brain or
spine. They happen when the neural tube (that
later turns into the brain and spine) doesn’t form
right, and the baby’s brain or spine is damaged.
This happens within the first few weeks a woman
is pregnant, often before a woman knows that she
is pregnant.”
According to the Spina Bifida Association (SBA),
the three types of spina bifida include occulta,
meningocele, and myelomeningocele. Regarding
the first and mildest type, the SBA said, “Often
called hidden spina bifida, the spinal cord and the
nerves are usually normal and there is no open-
ing on the back. In this usually harmless form of
spina bifida, there is a small defect or gap in a few
of the small bones (vertebrae) that make up the
spine. There may be no motor or sensory impair-
ments evident at birth; subtle, progressive neuro-
logic deterioration often becomes evident in later
childhood or adulthood. In many instances, spina
bifida occulta is so mild that there is no disturbance
of spinal function at all. Occulta can be diagnosed
at any age.” With the meningocele type, “the pro-
tective coatings (meninges) come through the open
spina bifida 265
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