PERCEPTION it is a mental process by which the brain selects, organizes and interprets these sensations.

COORDINATION - movement of parts together: the skillful and balanced movement of different parts, especially parts of the body, at the same time

GEOGRAPHY OF THE BRAIN



FRONTAL LOBE
   

Personality, behavior Motor function Brocas area (expressive speech) Concentration, abstract thoughts

PARIETAL LOBE
 

Sensation Awareness of body parts, orientation in space and spatial relationship

OCCIPITAL LOBE


Vision

TEMPORAL LOBE
  

Hearing, taste, smell Wernickes area (receptive speech) Interpretive area

BRAIN STEM ( pons, medulla, midbrain)



Cardiac, vasomotor, respiratory centers

THALAMUS


Interpretation of sensation

HYPOTHALAMUS
       

Temperature control Water metabolism Control of hormonal secretion Heart rate Peristalsis Appetite control Thirst center Sleep-wake cycle

CRANIAL NERVES conducts special senses (smell, visual, hearing). It also generalized sense impulses (pain, pressure, touch, vibration, temperature, deep muscle sense) voluntary muscle, control or somatic muscle impulses, involuntary control, or visceral effector messages to glands and involuntary muscles.

CRANIAL NERVES
    

I. Olfactory -smell II. Optic -vision III. Oculomotor - -contraction of most eye muscle IV. Trochlear - -movement of the eye V. Trigeminal -great sensory nerve of head and face VI. Abducens - -supplies one eyeball muscle

 

 

VII. Facial - - motor sensory(muscles) for facial expression VIII. Accoustic - hearing IX. Glossopharyngeal -general sense, impulse from tongue, pharynx, throat X. Vagus - secretory to glands producing digestive and other secretions. XI. Accessory - - motor to neck muscles XII. Hypoglossal - muscles for tongue

Sensory Perception


 

Sensory perception- involves the conscious organization and translation of the data or stimuli into meaningful information Sensory reception- process of receiving stimuli or data Kinesthetics- awareness of the position and movement of body parts Stereognosis- ability to perceive and understand an object through its size, shape and texture Visceral - any large organ within the body

Four aspects of sensory process

 

Stimulus an agent or act that stimulates a nerve receptor Receptor- a nerve cell that converts stimulus to a nerve impulse Impulse conduction- the impulse travels along nerve pathways to the spinal cord or directly to the brain Perception- perception, or awareness and interpretation of stimuli happens in the brain where specialized brain cells interpret the nature and quality of the sensory stimuli. The LOC affects the perception of stimuli

PROMOTING NORMAL SENSORY PERCEPTION

STRUCTURE and FUNCTION of SENSORY PERCEPTION



Sensory Awareness


Reticular activating system-responsible for bringing together information from the cerebellum and other parts of the brain with that obtained from the sense organs Special senses-vision, hearing, smell and taste Somatic senses-touch, kinesthetics (or proprioceptive) sensation, and visceral sensation

Input by senses
 

SENSORISTASIS


state of optimum arousal-not too much not too little beyond the point of sensoristasis ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and action.

ADAPTATION


AWARENESS


LIFESPAN CONSIDERATION
   

Newborn and Infant Toddler and Preschooler Child and adolescent Adult and Older Adult

FACTORS AFFECTING SENSORY PERCEPTION

      

Environment Previous Experience Lifestyle and Habits Illness Medications Variations in Stimulation Sensory deprivation

SENSORY ALTERATIONS


SENSORY DEPRIVATION- decrease in or lack of meaningful stimuli SENSORY DEFICIT- impaired reception, perception, or both, of one or more of the senses. SENSORY OVERLOAD- occurs when a person unable to process or manage the amount or intensity of the sensory stimuli  Factors:
  

Increased quality and quantity of internal stimuli Increased quality and quantity of external stimuli Inability to disregard stimuli selectively

ALTERED SENSORY PERCEPTION FUNCTION



Manifestations of Altered Sensory Perception function

    

Anxiety Cognitive Dysfunction Hallucinations and delusions Sensory deficits Depression and withdrawal

NURSING PROCESS

ASSESSMENT
 

Normal pattern identification Risk identification



Sensory overload Lengthy verbal explanations before the procedure  Room close to the nurses station  Bright lights  Use of ECG monitor, mechanical ventilators, Oxygen ,IV tubes other equipment  Frequent treatments Sensory deprivation  Private room, eyes bandaged, bedrest, sensory aid not available isolation precautions, few visitors

CHARACTERISTICS OF NORMAL SENSORY PERCEPTION  Normal vision-visual acuity at or near 20/20, full field of vision and tricolor vision (red, green and blue)  Normal hearing-auditory acuity of sounds at an intensity of 0 to 25 dB, at frequencies of 125 to 8000 cycles per second  Normal taste- ability to discriminate sour, salty, sweet and bitter  Normal smell-discrimination of primary odours such as musky, floral, pepperminty, pungent  Somatic senses-discrimination of touch, pressure, vibration, position, tickling, temperature and pain

State of Awareness


State Description
Alert; oriented to time, place, person; understands verbal and written words Not oriented to time, place, or person Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment Extreme drowsiness but will respond to stimuli Can be aroused by extreme or repeated stimuli Will not respond to verbal stimuli

Full consciousness

 

Disoriented Confused

  

Somnolent Semicomatose Coma

Assessing Sensory Perception

 

Vision- use of snellen chart to measure visual acuity (or have the client read newspaper, menu or whatever) Smell- with eyes closed, have client identify 3 odors, such as coffee, tobacco and cloves, one nostril at a time, while occluding the other nostril Hearing- whisper numbers in each ear, while occluding the other; ask the client to repeat; perform Weber and Rinne tuning fork test
  

WEBERS TEST- assesses bone conduction by testing the lateralization ( sideward transmission) of sounds. RINNE TEST- test compares air conduction to bone conduction Sound conducted by air is heard more readily than sound conducted by bone.

Taste-with eyes closed, have client identify 3 tastes such as lemon, salt, and sugar, waiting 1 minute and giving sips of water in between. Somatic sensations-Test light touch of extremities with a wisp of cotton; test sharp and dull sensation using the point and blunt end of a pin; test two-point discrimination using two pins held close together; test hot and cold sensation using test tube filled with warm and cold water; test position sense by moving the clients fingers or toes

Diagnosing
      

Disturbed sensory perception Risk for injury Impaired home maintenance Risk for impaired skin integrity Impaired verbal communication Self care deficit Social isolation

Planning


The overall outcome criteria for clients with sensory-perception alterations are to:
     

Maintain the function of existing senses Develop an effective communication mechanism Prevent injury Prevent sensory overload or deprivation Reduce social isolation Perform ADLs independently and safely

IMPLEMENTATION


HEALTH PROMOTION
  

Client Teaching Procedure preparation Nurse-client Interaction

NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION

  

Stimulation Provision Stimulation Reduction Sensory Aids

SENSORY AIDS


VISION
        

Eyeglasses with proper prescription, clean and in good repair Adequate room lighting, drapes open Sunglasses or window shades to reduce glare Literature with large print Uncluttered environment, no furniture arrangement Clock with large numbers Telephone dial with large numbers Magnifying glass Bright, contrasting colors in environment

 Hearing
 

   

Hearing aid in good repair with working battery Speaking slowly and distinctly in clients full view, no mouth covering or gum chewing Avoidance of background noise Amplified phone ringer, doorbell, smoke alarm Headset for telephone communication Closed-caption television

Smell
 

Fresh food served for meals Fresh flower or fragrance in the room Others wearing light perfume or fragrance Notice of environmental smells

TASTE


  

Fresh food, seasoned, appropriately, not overcooked or overprocessed to preserve texture Foods served at appropriate temperature and time of a day Note smell and taste of food Sips of water between foods No mixing of foods

Touch
   

 

Therapeutic touch Massage (self or Nurse) Turning and repositioning Hairbrushing and grooming (self or nurse) Activity around the environment Amount of pressure individualized to clients comfort level Clothing of various texture

 

Promoting the use of other Senses Communicating effectively



Conscious and unconscious client

Ensuring client safety

Diet


Diet a balance diet is important in maintaining the bones or muscles for optimum activity. should contain adequate sources of calcium, phosphorus and vitamin D for bone growth and prevention of osteoporosis. The diet should contain adequate sources of the following;

Calcium for bone and teeth formation, blood clotting, muscle activity and nerve function.


High Calcium dried and fresh dilis, dried and fresh alamang, fried fish, shell fish, certain fresh fishes such as silinyasi, tunsoy, milk, cheese, ice cream, soy beans, monggo and other dried beans, leafy vegetables. Low Calcium cereal and cereal products without milk, fruit and fruit juices, vegetables, lean meat. Poultry sugar starchy roots and tubers, young coconut.

Phosphorus for bone and teeth formation, important in energy transfer, component of nucleic acid.


High Phosphorus Meat, fish, poultry, egg yolk, milk, cheese, beans and bean products, nuts and seeds, dried banana and flowers, cocoa, chocolate, undermilled rice, pinipig, whole grain cereal, cookies and sweet made with nuts. Low Phosphorus Egg white, sugar, fats and oil, fruits, kaong, gabi stem, sayote, bihon, sotanghon, kusinta and nata de coco

EXERCISE


CLASSIFICATION


Source of Energy
 

Aerobic Exercise Anaerobic Exercise

Type of Muscle Tension

 

Isotonic Exercise Isometric Exercise

Effects of Exercise on:

     

Cardiovascular System Respiratory System Endocrine System Immune System Muscular System Metabolic Rate

FACTORS AFFECTING MOBILITY

      

Lifestyle and habits Intact musculoskeletal system Nervous system control Circulation and Oxygenation Energy Congenital problems Therapeutic modalities

Manifestations of Altered Mobility

      

Decreased muscle tone and strength Lack of coordination Altered gait Falls Decreased joint flexibility Pain on movement Activity intolerance

Impact of Immobility on Function



Activity and Exercise

muscle atrophy and weakness  contractures and joint pains  increased cardiac workload  orthostatic hypotension  thrombus formation and embolism  decreased lung expansion


Nutrition and Metabolism

     

Decreased metabolic rate Negative nitrogen balance Anorexia Disuse osteoporosis Impaired immunity Pressure Ulcers

 ELIMINATION

   

Urinary stasis urinary tract infection renal calculi constipation

     

SLEEP and REST COGNITION and PERCEPTION SELF-PERCEPTION and SELF-CONCEPT ROLES and RELATIONSHIP COPING and STRESS TOLERANCE SEXUALITY

Muscle Strength Grading

     

0 No contraction 1 Slight contraction, no movement 2 Full range of motion without gravity 3 Full range of motion with gravity 4 Full range of motion , some resistance 5 Full range of motion, full resistance

Grading DTR's
    

0 Absent 1 Decreased but present 2 Normal 3 Brisk and excessive 4 With clonus

GLASGOW COMA SCALE (GCS)

  

is an objective measure to describe LOC it is based on the clients response in 3 areas: eye opening ,verbal response, motor response


  

GLASGOW COMA SCALE

Score 15 = patient is awake and oriented 7 or below coma Lowest score 3 deep coma

NURSING INTERVENTIONS for ALTERED MOBILITY

POSITIONING
  

Think through the task before beginning Ensure that all needed equipment is within reach Explain to the client exactly what will happen before the beginning of position change Enlist the clients assistance whenever possible, giving instructions and encouragement as necessary When the position change has been completed, ask if the client is comfortable. Reposition as necessary Tell the client how long he or she will remain in the position. Provide a call device within reach. Document position changes and the clients tolerance.

JOINT MOBILITY MAINTENANCE

 

Types of ROM General Principles of ROM Exercises



Guidelines for moving clients  Assess the clients abilities and limitations  Medicate client to provide optimal pain relief  Organize environment and request needed help to ensure safety  Explain what you are going to do and how you expect your client to help

Neurological System Examinations

NEUROLOGICAL SYSTEM DIAGNOSTICS

SKULL AND SPINE X-RAY STUDIES



Simple x-ray films are obtained to determine fractures, calcifications, etc.

ELECTROENCEPHALOGRAPH Y-(EEG)


a recording of the electrical activity of the brain to physiologically assess cerebral activity; useful for diagnosing seizure disorders; used as screening procedure for coma; also serve as an indicator for brain death. May also be used to assess sleep disorders, metabolic disorders and encephalitis.

Nursing Implications:


Explain to client that procedure is painless and there is no danger of electrical shock. Determine from physician if any medication should be withheld before the test, especially tranquilizers and sedatives. Frequently, coffee, tea, cola, and other stimulants are prohibited before examination. Clients hair should be clean before the examination: after exam, assist client to wash electrode paste out of hair.

MAGNETIC RESONANCE IMAGING



Cell nuclei have magnetic properties; the MRI machine records the signals from the cells in a manner that provides information to evaluate soft tissue structures (tumors, blood vessels)

Nursing Implications:
  

Procedure will take approximately 1 hour. All metal objects should be removed from the client. The client will be placed in a long magnetic tunnel for the procedure. Poor candidates for MRI include the following:
    

Clients with pacemakers Clients with implanted insulin pumps Pregnant clients Obese clients Any client who requires life support equipment

COMPUTERIZED AXIAL TOMOGRAPHY SCAN (CAT)



Computer-assisted xray examination of thin cross-sections of the brain to identify hemorrhage, tumor, edema, infarctions, and hydrocephalus. Machine is large donut shaped tube with table through the middle.

Nursing Implications:


Explain appearance of scanner to client and explain importance of remaining absolutely still during the procedure. Remove all objects from clients hair; clients only receives fluid for 4-6 hours before the test. Dye will be injected via venipuncture; assess for iodine allergy and advise the client that he/she may experience a flushing or warm sensation when the dye is injected. Contrast dye may discolor urine for about 24 hours.

LUMBAR PUNCTURE


A needle is inserted into the lumbar area at the L4-L5 level; spinal fluid is withdrawn, and spinal fluid pressure is measured; contraindicated in presence of increased ICP. Normal spinal fluid values; opening pressure, 60-150 mm water; specific gravity 1.007; pH 7.35; clear fluid; protein concentration,15-45 mg/dl; glucose concentration 4575 mg/dl; no microorganism present.

Nursing Implication:


Before the test

  

have client empty the bladder. Explain position (lateral recumbent with knees flexed) Advised physician if there is a change in neurological status of the client before the test; increased ICP is a contraindication to lumbar puncture. Keep the client flat at least 3 hours, and sometimes up to 12 hours, to decrease occurrence of headache. Encourage high fluid intake Observe for spinal fluid leak fro the puncture site; if leakage occurs, it may precipitate a severe headache.

After the test

  

Hydrocephalus


is a condition in which dilated cerebral ventricles inhibit normal flow of cerebrospinal fluid (CSF). The CSF accumulates in the skull and puts pressure on the brain tissue. An enlarged head in infants and increased CSF pressure are frequent findings but are not necessary for the diagnosis. Hydrocephalus is sometimes inaccurately referred to as "water on the brain."

Description of Hydrocephalus


Normally, CSF is secreted in the cavities of the brain and absorbed by a membrane that lines the cavities. If the membrane does not absorb the fluid or if the fluid is blocked, it builds up in the cavities. The fluid buildup causes the head to become enlarged and the brain to become compressed. This condition can lead to paralysis, blindness, mental retardation, inability to speak, and convulsions.

Etiology:


Congenital hydrocephalus usually results from defects, such as Chairi malformations. It is also associated with spina bifida. Acquired hydrocephalus usually results from space-occupying lesions, hemorrhage, intracranial infections or dormant development defects.

Classification of Hydrocephalus:


Hydrocephalus can be caused by

  

Impaired cerebrospinal fluid(CSF) flow, reabsorption, or excessive CSF production.

The most common cause of hydrocephalus is CSF flow obstruction, hindering the free passage of cerebrospinal fluid through the ventricular system and subarachnoid space (e.g., stenosis of the cerebral aqueduct or obstruction of the interventricular foramina foramina of Monro secondary to tumors, hemorrhages, infections or congenital malformations). Hydrocephalus can also be caused by overproduction of cerebrospinal fluid (relative obstruction) (e.g., papilloma of choroid plexus).

Communicating


Communicating hydrocephalus, also known as non-obstructive hydrocephalus In communicating hydrocephalus, there is no obstruction in the ventricular system - the CSF flows readily into the subarachnoid space but is insufficiently absorbed, or perhaps produced in too great a quantity to be absorbed.

Non-communicating


Non-communicating hydrocephalus, or obstructive hydrocephalus, is caused by a CSF-flow obstruction (either due to external compression or intraventricular mass lesions). In noncommunicating (obstructing) hydrocephalus, a ventricular block to CSF flow causes dilation of the pathways upstream of the block, leading to increased CSF pressure in the skull.

Causes and Risk Factors of Hydrocephalus



Hydrocephalus is usually the result of a brain infection or a malformation in the fetus prior to birth. Although the baby's head may not appear abnormally large at birth, it expands rapidly from month to month. If untreated, the baby usually dies by the end of the second year. If the blockage of CSF is only partial, the child may live for a number of years or may even live a normal life span.

Clinical Manifestations:
          

Abnormal rate of head growth Bulging fontanelle Tense anterior fontanelle (often bulging and nonpulsatile) Dilated scalp veins Macewens sign (cracked pot) Frontal bossing Setting sun sign Sluggish and unequal pupils Irritability and lethargy with varying LOC Abnormal infantile reflexes Possible cranial nerve damage

Laboratory and Diagnostic Study Findings:



 

Level II ultrasonography of the fetus will allow a prenatal diagnosis. (Transuterine placement of ventriculoamniotic shunts during late pregnancy is still being developed as a treatment modality). CT scan will diagnose most cases postnatally. MRI can be used if a complex lesion is suspected.

Nursing Management:


Teach the family about the management required for the disorder


Treatment is surgical by direct removal of an obstruction and insertion of shunt to provide primary drainage of the CSF to an extracranial compartment, usually peritoneum (ventriculoperitoneal shunt)  The major complications of shunts are infections and malfunction  Other complications include subdural hematoma caused by a too rapid reduction of CSF, peritonitis, abdominal abscess, perforation of organs, fistulas, hernias and ileus. A third ventriculostomy is a new nonshunting procedure used to treat children with hydrocephalus.

Provide preoperative nursing care



Assess head circumference, fontanelles, cranial sutures, and LOC; check also for irritability, altered feeding habits and a high-pitched cry. Firmly support the head and neck when holding the child. Provide skin care for the head to prevent breakdown. Give small, frequent feedings to decrease the risk of vomiting. Encourage parental-newborn bonding.

Provide Postoperative nursing care (nursing interventions are the same as those for increased ICP)  Assess for signs of increased ICP and check the following; head circumference (daily), anterior fontanelle for size and fullness and behavior.  Administer prescribed medications which may include antibiotics to prevent infection and analgesics for pain.  Provide shunt care


Monitor for shunt infection and malfunction which may be characterized by rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness along the shunt tract, and fluid around the shunt valve. Prevent infection (usually from Staphylococcus epidermis or Staphylococcus aureus) Monitor for shunt overdrainage (headache, dizziness and nausea). Overdrainage may lead to slit ventricle syndrome whereby the ventricle become accustomed to a very small or slitlike configuration, limiting the buffering ability to increased ICP variations.

Teach home care



Encourage the child to participate in ageappropriate activities as tolerated. Encourage the parents to provide as normal lifestyle as possible. Remind both the child and parents that contact sports are prohibited. Explain how to recognize signs and symptoms of increased ICP. Subtle signs include changes in school performance, intermittent headache, and mild behavior changes. Arrange for the child to have frequent developmental screenings and routine medical checkups.

Spina Bifida


 

Is a developmental anomaly characterized by defective closure of the bony encasement of the spinal cord through which the spinal cord and meninges may or may not protrude. If the anomaly is not visible, the condition is called spina bifida occulta. If there is an external protrusion of the saclike structure, the condition is called spina bifida cystica, and is further classified according to extent of neural involvement (e.g., meningocele, meningomyelocele, or myelomeningocele).

Spina bifida is a congenital disorder (birth defect) in which the backbone and spinal canal do not close before birth. In severe cases, this can result in the spinal cord and its covering membranes protruding out of an affected infant's back. Spina bifida may also be nearly inconsequential, or may be repairable through surgery.

Types of spina bifida

1. Occulta is the mildest and most common form in which one or more vertebrae are malformed. The name "occulta," which means "hidden," indicates that the malformation, or opening in the spine, is covered by a layer of skin. This form of spina bifida rarely causes disability or symptoms.

2.Closed neural tube defects make up the second type of spina bifida. This form consists of a diverse group of spinal defects in which the spinal cord is marked by a malformation of fat, bone, or membranes. In some patients there are few or no symptoms; in others the malformation causes incomplete paralysis with urinary and bowel dysfunction.

3.Meningocele, the meninges protrude from the spinal opening, and the malformation may or may not be covered by a layer of skin. Some patients with meningocele may have few or no symptoms while others may experience symptoms similar to closed neural tube defects.

4.Myelomeningocele, the fourth form, is the most severe and occurs when the spinal cord is exposed through the opening in the spine, resulting in partial or complete paralysis of the parts of the body below the spinal opening. The paralysis may be so severe that the affected individual is unable to walk and may have urinary and bowel dysfunction.

Signs and symptoms of spina bifida



The symptoms of spina bifida vary from person to person, depending on the type.  Often, individuals with occulta have no outward signs of the disorder.  Closed neural tube defects are often recognized early in life due to an abnormal tuft or clump of hair or a small dimple or birthmark on the skin at the site of the spinal malformation.  Meningocele and myelomeningocele generally involve a fluidfilled sac visible on the back protruding from the spinal cord.
 

In meningocele, the sac may be covered by a thin layer of skin, whereas in most cases of myelomeningocele, there is no layer of skin covering the sac and a section of spinal cord tissue usually is exposed.

Complications of spina bifida



In addition to loss of sensation and paralysis, another neurological complication associated with spina bifida is Chiari II malformation a rare condition (but common in children with myelomeningocele) in which the brainstem and the cerebellum, or rear portion of the brain, protrude downward into the spinal canal or neck area. This condition can lead to compression of the spinal cord and cause a variety of symptoms including difficulties with feeding, swallowing, and breathing; choking; and arm stiffness.

Chiari II malformation may also result in a blockage of cerebrospinal fluid, causing a condition called hydrocephalus, which is an abnormal buildup of cerebrospinal fluid in the brain.

Some newborns with myelomeningocele may develop meningitis, an infection in the meninges. Meningitis may cause brain injury and can be life-threatening.

Children with both myelomeningocele and hydrocephalus may have learning disabilities, including difficulty paying attention, problems with language and reading comprehension, and trouble learning math. Additional problems such as latex allergies, skin problems, gastrointestinal conditions, and depression may occur as children with spina bifida get older.

Diagnosis of spina bifida



Prenatal diagnosis The most common screening methods used to look for spina bifida during pregnancy are second trimester maternal serum alpha fetoprotein (MSAFP) screening and fetal ultrasound.  The MSAFP screen measures the level of a protein called alphafetoprotein (AFP), which is made naturally by the fetus and placenta. During pregnancy, a small amount of AFP normally crosses the placenta and enters the mother's bloodstream. But if abnormally high levels of this protein appear in the mother's bloodstream it may indicate that the fetus has a neural tube defect. The MSAFP test, however, is not specific for spina bifida, and the test cannot definitively determine that there is a problem with the fetus. If a high level of AFP is detected, the doctor may request additional testing, such as an ultrasound or amniocentesis to help determine the cause.

The most common screening methods used to look for spina bifida during pregnancy are second trimester maternal serum alpha fetoprotein (MSAFP) screening and fetal ultrasound.

Postnatal diagnosis Mild cases of spina bifida not diagnosed during prenatal testing may be detected postnatally by Xray during a routine examination.


Doctors may use magnetic resonance imaging (MRI) or a computed tomography (CT) scan to get a clearer view of the spine and vertebrae. Individuals with the more severe forms of spina bifida often have muscle weakness in their feet, hips, and legs. If hydrocephalus is suspected, the doctor may request a CT scan and/or X-ray of the skull to look for extra fluid inside the brain.

Mild cases of spina bifida not diagnosed during prenatal testing may be detected postnatally by X-ray during a routine examination.

Care of Myelomeningocele Sac

Keep warm (Incubator/warmer) No clothing Moist dressings Observe for early signs of infection Prevent stool contamination POSITIONING

Prevent Complications Position Diapering Skin breakdown Contractures Tactile stimulation

Postoperative Care Vital signs I&O Nutrition Infection Pain management Wound management Position Decrease latex exposure Family education Family support Rehabilitation

Head Injury


A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.

Classification of Head Injury



A closed head injury means receiving a hard blow to the head from striking an object, but the object did not break the skull. An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

Types of Brain Injury

The most common type of traumatic brain injury, in which the brain is shaken

A concussion may result when the head strikes against an object or is struck by an object. Concussions may produce unconsciousness or bleeding in or around the brain.

Contusion, which is a bruise on the brain

Causes:


Common causes of head injury include

   

traffic accidents, falls, physical assault, and accidents at home, work, outdoors, or while playing sports.

Some head injuries result in prolonged or nonreversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. These more serious head injuries may cause:
     

Coma Chronic headaches Loss of or change in sensation, hearing, vision, taste, or smell Paralysis Seizures Speech and language problems

Head Injury

Head injuries can range from a minor bump on the head to a devastating brain injury. Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life. Common causes of head injury include traffic accidents, falls, physical assault, and accidents at home, work, outdoors, or while playing sports.

Signs of Head Injury

Helmets can save lives and prevent trauma, but only if they are worn properly. A helmet should be worn squarely on the top of the head, covering the top of the forehead. The chinstrap must be fastened and the helmet should fit snugly and comfortably. The helmet should not be able to move side-to-side or front-to-back. Most helmets come with removable pads so you can customize the fit for any child.

Spinal Cord Injury



A spinal cord injury often causes permanent disability or loss of movement (paralysis) and sensation below the site of the injury.

A severe spinal cord injury often causes loss of feeling and paralysis, the loss of movement and voluntary control over the muscles in the body. Spinal cord damage also causes loss of reflex function below the point of injury interrupting bodily functions such as breathing, bowel control, and bladder control. In the event of a spinal injury prompt medical attention can help to minimize further spinal cord damage.

The completeness of the injury is classified as either:



Complete. If all sensory (feeling) and motor function (ability to control movement) is lost below the neurological level, the injury is called complete. Incomplete. If you have some motor or sensory function below the affected area, the injury is called incomplete.

Additionally, paralysis from a spinal cord injury may be referred to as:



Tetraplegia or quadriplegia. This means your arms, trunk, legs and pelvic organs are all affected by your spinal cord injury.

Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.

Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:
 

   

Loss of movement Loss of sensation, including the ability to feel heat, cold and touch Loss of bowel or bladder control Exaggerated reflex activities or spasms Changes in sexual function, sexual sensitivity and fertility Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms Emergency signs and symptoms of spinal cord injury after an accident may include:
      

Extreme back pain or pressure in your neck, head or back Weakness, incoordination or paralysis in any part of your body Numbness, tingling or loss of sensation in your hands, fingers, feet or toes Loss of bladder or bowel control Difficulty with balance and walking Impaired breathing after injury An oddly positioned or twisted neck or back

Causes:


Injury may be traumatic or nontraumatic



A traumatic spinal cord injury may stem from a sudden, traumatic blow to the spine that fractures, dislocates, crushes or compresses one or more of the vertebrae. It may also result from a gunshot or knife wound that penetrates and cuts the spinal cord. Additional damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around the spinal cord.

A nontraumatic spinal cord injury may be caused by arthritis, cancer, inflammation or infections, or disk degeneration of the spine.

Damage to nerve fibers



Whether the cause is traumatic or nontraumatic, the damage affects the nerve fibers passing through the injured area and may impair part or all of the corresponding muscles and nerves below the injury site. A chest (thoracic) or lower back (lumbar) injury can affect the chest, abdomen, legs, bowel and bladder control, and sexual function. In addition, a neck (cervical) injury affects movements of arms and, possibly, the ability to breathe.

Common causes of spinal cord injury



 

accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than 40 percent of new spinal cord injuries each year. Acts of violence. As many as 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds, according to the National Institute of Neurological Disorders and Stroke. Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause about one-quarter of spinal cord injuries. Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 8 percent of spinal cord injuries. Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries. Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Being a man. Spinal cord injuries affect a disproportionate amount of men. In fact, women account for only about 20 percent of spinal cord injuries in the United States.

Being between the ages of 16 to 30. You're most

likely to suffer a spinal cord injury if you're between the ages 16 and 30. Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65, while falls cause most injuries in older adults.

Being active in certain sports. While being active is

one of the best things you can do for your overall health, it may place you at greater risk of a spinal cord injury. Athletic activities that may increase your risk of a spinal cord injury include football, rugby, wrestling, gymnastics, horseback riding, diving, surfing, roller-skating, in-line skating, ice hockey, downhill skiing and snowboarding.

Having an underlying bone or joint disorder. A relatively minor injury can cause a spinal cord injury if you have another disorder that affects your bones or joints, such as arthritis or osteoporosis.

Complications
       

Bladder control. Bowel control. Impaired skin sensation. Circulatory control Respiratory system Muscle tone Fitness and wellness Sexual health

There's usually no physical change in women with a spinal cord injury that inhibits sexual intercourse or pregnancy. Most women with a spinal cord injury can experience labor, have a normal delivery and breast-feed. Pain. Some people may experience pain, such as muscle or joint pain from overuse of particular muscle groups. Nerve pain, also known as neuropathic or central pain, can occur after a spinal cord injury, especially in someone with an incomplete injury.

Test and Diagnosis

   

X-rays. Computerized tomography (CT) scan. Magnetic resonance imaging (MRI).. Myelography.

Treatments and Drugs



Early (acute) stages of treatment In the emergency room, doctors focus on:
  

Maintaining ability to breathe Preventing shock Immobilizing the neck to prevent further spinal cord damage Avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and formation of deep vein blood clots in the extremities

Medications. Methylprednisolone (Medrol) is a treatment option for an acute spinal cord injury. If methylprednisolone is given within eight hours of injury, some people experience mild improvement from their spinal cord injury. It appears to work by reducing damage to nerve cells and decreasing inflammation near the site of injury. However, this is not a cure for a spinal cord injury. Immobilization. Patient may need traction to stabilize the spine, to bring the spine into proper alignment or both. Sometimes, traction is accomplished by securing metal braces, attached to weights or a body harness, to the skull to keep the head from moving. In some cases, a rigid neck collar also may work. A special bed also may help immobilize the body. Surgery. Often, surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity. Experimental treatments. Scientists are trying to figure out ways to stop cell death, control inflammation and promote nerve regeneration.

Ongoing care After the initial injury or disease stabilizes, doctors turn their attention to preventing secondary problems that may arise, such as deconditioning, muscle contractures, pressure ulcers, bowel and bladder issues, respiratory infections and blood clots. The length of hospitalization depends on the individual condition and what medical issues they're facing. Once they're well enough to participate in therapies and treatment, they may transfer to a rehabilitation facility.

Rehabilitation. Rehabilitation team members may begin to work with while patient is in the early stages of recovery. The team may include a physical therapist, occupational therapist, rehabilitation nurse, rehabilitation psychologist, social worker, dietitian, recreation therapist and a doctor who specializes in physical medicine (physiatrist) or spinal cord injuries.

Medications. Medications may be used to manage some of the effects of spinal cord injury. These include medications to control pain and muscle spasticity, as well as medications that can improve bladder control, bowel control and sexual functioning.

New technologies. Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. Some devices may also restore function. These include: Modern wheelchairs. Improved, lighter weight wheelchairs are making people with a spinal cord injury more mobile and more comfortable. For some, an electric wheelchair may be needed. Some wheelchairs can even climb stairs, travel over rough terrain and elevate a seated passenger to eye level to reach high places without help. Computer adaptations. For someone that has limited hand function, computers can be very powerful tools, but they're difficult to operate. Some examples of computer adaptations range from simple to complex, such as key guards or voice recognition.

Electronic aids to daily living. Essentially any device that uses electricity can be controlled with an electronic aid to daily living (EADL). Devices can be turned on or off by switch or voice-controlled and computer-based remotes. Electrical stimulation devices. These sophisticated devices use electrical stimulation to produce actions. They're often called functional electrical stimulation (FES) systems, and they use electrical stimulators to control arm and leg muscles to allow people with a spinal cord injury to stand, walk, reach and grip.

Prognosis and recovery It's often impossible for the doctor to make a precise prognosis right away. Recovery, if it occurs, typically starts between a week and six months after an injury. However, some people experience small improvements for up to one year or longer.

Cerebrovascular accident


Stroke is a sudden loss of consciousness and sensation caused by an interruption in the flow of blood to part or all of the brain. Stroke is also known as brain attack and cerebrovascular accident (CVA), but the term stroke best describe the dramatic suddenness with which the disorder usually strikes. Stroke is one of the leading causes of death worldwide.

The most common type of stroke is known as an ischemic stroke. Nearly nine out of 10 strokes fall into this category. The culprit is a blood clot that obstructs a blood vessel inside the brain. The clot may develop on the spot or travel through the blood from elsewhere in the body.

Hemorrhagic strokes are less common but far more likely to be fatal. They occur when a weakened blood vessel in the brain bursts. The result is bleeding inside the brain that can be difficult to stop.

Risk Factors: Chronic Conditions



    

Certain chronic conditions increase your risk of stroke. These include: High blood pressure High cholesterol Diabetes Obesity Taking steps to control these conditions may reduce your risk.

Risk Factors: Behaviors



 

Certain behaviors also increase the risk of stroke: Smoking Getting too little exercise Heavy use of alcohol

Risk Factors: Diet

 

A poor diet may increase the risk for stroke in a few significant ways. Eating too much fat and cholesterol can lead to arteries that are narrowed by plaque. Too much salt may contribute to high blood pressure. And too many calories can lead to obesity. A diet high in fruits, vegetables, whole grains, and fish may help lower stroke risk.

Risk Factors You Can't Control



Some stroke risk factors are beyond your control, such as getting older or having a family history of strokes. Gender plays a role, too, with men being more likely to have a stroke. However, more stroke deaths occur in women. Finally, race is an important risk factor. African-Americans, Native Americans, and Alaskan Natives are at greater risk compared to people of other ethnicities.

Risk factors
              

history of transient ischemic attacks (TIAs), atherosclerosis, hypertension, electrocardiogram changes, arrhythmias, rheumatic heart disease, diabetes mellitus, gout, postural hypotension, cardiac or myocardial enlargement, high serum triglyceride levels, lack of exercise, use of hormonal contraceptives, cigarette smoking, and family history of stroke.

Thrombosis


In middle-aged and elderly people among whom theres a higher incidence of atherosclerosis, diabetes, and hypertension thrombosis is the most common cause of stroke. Obstruction of a blood vessel causes the stroke. Typically, the main site of the obstruction is the extracerebral vessels, but sometimes its the intracerebral vessels.

Embolism


The second most common cause of stroke, embolism is an occlusion of a blood vessel caused by a fragmented clot, a tumor, fat, bacteria, or air. It can occur at any age, especially among patients with a history of rheumatic heart disease, endocarditis, posttraumatic valvular disease, or myocardial fibrillation and other cardiac arrhythmias or after open-heart surgery or placement of a mechanical heart valve.

Hemorrhage


 

The third most common cause of stroke is hemorrhage. Like an embolism, it may occur suddenly, at any age. Such hemorrhage results from chronic hypertension or aneurysms, which cause sudden rupture of a cerebral artery. The rupture diminishes blood supply to the area served by this artery. In addition, blood accumulates deep within the brain, further compressing neural tissue and causing even greater damage.

F = FACE Ask the person to smile. Does one side of the face droop? A = ARM Ask the person to raise both arms. Does one arm drift downward? S = SPEECH Ask the person to repeat a simple phrase. Does the speech sound slurred or strange? T = TIME If you observe any of these signs, its time to call 9-1-1.

Stroke: Time = Brain Damage



Every second counts when seeking treatment for a stroke. When deprived of oxygen, brain cells begin dying within minutes. There are clot-busting drugs that can curb brain damage, but they have to be used within three hours of the initial stroke symptoms. Once brain tissue has died, the body parts controlled by that area won't work properly. This is why stroke is a top cause of long-term disability.

Diagnosing a Stroke


When someone with stroke symptoms arrives in the ER, the first step is to determine which type of stroke is occurring. There are two main types, and they are not treated the same way. A CT scan can help doctors determine whether the symptoms are coming from a blocked blood vessel or a bleeding one. Additional tests may also be used to find the location of a blood clot or bleeding within the brain.

Stroke: Emergency Treatment



For an ischemic stroke, emergency treatment focuses on medicine to restore blood flow. A clotbusting medication is highly effective at dissolving clots and minimizing long-term damage, but it must be given within three hours of the onset of symptoms. Hemorrhagic strokes are more difficult to manage. Treatment usually involves attempting to control high blood pressure, bleeding, and brain swelling.

Ultrasound Beams Could Destroy Stroke-Causing Blood Clots in the Brain

Stroke: Long-Term Damage



Whether a stroke causes longterm damage depends on its severity and how quickly treatment stabilizes the brain. The type of damage depends on where in the brain the stroke occurs. Common problems after a stroke include numbness in the arms or legs, difficulty walking, vision problems, trouble swallowing, and problems with speech and comprehension. These problems can be permanent, but many people regain most of their abilities.

Stroke Rehab: Speech Therapy



Rehabilitation is the centerpiece of the stroke recovery process. It helps patients regain lost skills and learn to compensate for damage that can't be undone. The goal is to help restore as much independence as possible. For people who have trouble speaking, speech and language therapy is essential. A speech therapist can also help patients who have trouble swallowing

Stroke Rehab: Physical Therapy



Muscle weakness, as well as balance problems, are very common after a stroke. This can interfere with walking and other daily activities. Physical therapy is an effective way to regain strength, balance, and coordination. For fine motor skills, such as using a knife and fork, writing, and buttoning a shirt, occupational therapy can help.

Stroke Rehab: Talk Therapy



It's common for stroke survivors and their loved ones to experience a wide range of intense emotions, such as fear, anger, worry, and grief. A psychologist or mental health counselor can provide strategies for coping with these emotions. A therapist can also watch for signs of depression, which frequently strikes people who are recovering from a stroke.

Stroke Prevention: Lifestyle



   

People who have had a stroke or TIA can take steps to prevent a recurrence: Quit smoking. Exercise and maintain a healthy weight. Limit alcohol and salt intake. Eat a healthier diet with more veggies, fish, and whole grains.

Stroke Prevention: Medications



For people with a high risk of stroke, doctors often recommend medications to lower this risk. Anti-platelet medicines, including aspirin, keep platelets in the blood from sticking together and forming clots. Anti-clotting drugs, such as warfarin, may be needed to help ward off stroke in some patients. Finally, if you have high blood pressure, your doctor will prescribe medication to lower it.

Stroke Prevention: Surgery



In some cases, a stroke results from a narrowed carotid artery -- the blood vessels that travel up each side of the neck to bring blood to the brain. People who have had a mild stroke or TIA due to this problem may benefit from surgery known as carotid endarterectomy. This procedure removes plaque from the lining of the carotid arteries and can prevent additional strokes.

Stroke Prevention: Balloon and Stent



Doctors can also treat a clogged carotid artery without major surgery in some cases. The procedure, called angioplasty, involves temporarily inserting a catheter into the artery and inflating a tiny balloon to widen the area that is narrowed by plaque. A metal tube, called a stent, can be inserted and left in place to keep the artery open.

Life After a Stroke



More than half of people who have a stroke regain the ability to take care of themselves. Those who get clotbusting drugs soon enough may recover completely. And those who experience disability can often learn to function independently through therapy. While the risk of a second stroke is higher at first, this risk drops off over time.

A transient ischemic attack (TIA) is caused by a temporary state of reduced blood flow in a portion of the brain. This is most frequently caused by tiny blood clots that temporarily occlude a portion of the brain. A primary blood supply to the brain is through two arteries in the neck (the carotid arteries) that branch off within the brain to multiple arteries that supply specific areas of the brain. During a TIA, the temporary disturbance of blood supply to an area of the brain results in a sudden, brief decrease in brain function.

During a transient ischemic attack (TIA), blood flow to part of the brain is temporarily blocked or reduced, often by a blood clot. This causes the same symptoms as a stroke, but after a few minutes, blood flow is restored and the symptoms go away

Symptoms of a TIA are like other stroke symptoms, but do not last as long. They happen suddenly, and include


 

Numbness or weakness, especially on one side of the body Confusion or trouble speaking or understanding speech Trouble seeing in one or both eyes Loss of balance or coordination

TIAs are often a warning sign for future strokes. Taking medicine, such as blood thinners, may reduce the risk of a stroke Your doctor might also recommend surgery.

Carotid Artery Surgery

A cerebral aneurysm (also called an intracranial aneurysm or brain aneurysm) is a bulging, weakened area in the wall of an artery in the brain, resulting in an abnormal widening or ballooning. Because there is a weakened spot in the artery wall, there is a risk for rupture (bursting) of the aneurysm.

cerebral aneurysm generally occurs in an artery located in the front part of the brain which supplies oxygen-rich blood to the brain tissue. A normal artery wall is made up of three layers. The aneurysm wall is thin and weak because of an abnormal loss or absence of the muscular layer of the artery wall, leaving only two layers.

The most common type of cerebral aneurysm is called a saccular, or berry, aneurysm, occurring in 90 percent of cerebral aneurysms. This type of aneurysm looks like a "berry" with a narrow stem. More than one aneurysm may be present at the same time.

A fusiform aneurysm bulges out on all sides (circumferentially). Fusiform aneurysms are generally associated with atherosclerosis.

A dissecting aneurysm may result from a tear in the inner layer of the artery wall, causing blood to leak into the layers. This may cause a ballooning out on one side of the artery wall or it may block off or obstruct blood flow through the artery. Dissecting aneurysms may occur with traumatic injury

The symptoms of an unruptured cerebral aneurysm include, but are not limited to, the following:
   

headaches dizziness eye pain vision deficits (problems with seeing)

A ruptured intracranial aneurysm causes intracranial bleeding and is considered very dangerous.

The first evidence of a cerebral aneurysm may be a subarachnoid hemorrhage (SAH), due to rupture of the aneurysm. Symptoms that may occur at the time of SAH include, but are not limited to, the following:  initial sign - rapid onset of "worst headache ever in my life"  stiff neck  nausea and vomiting  changes in mental status, such as drowsiness  pain in specific areas, such as the eyes  dilated pupils  loss of consciousness  hypertension (high blood pressure)  motor deficits (loss of balance or coordination)  photophobia (sensitivity to light)  back or leg pain  cranial nerve deficits (problems with certain functions of the eyes, nose, tongue, and/or ears that are controlled by one or more of the 12 cranial nerves)

Treatment


open craniotomy (surgical clipping) This procedure involves the surgical removal of part of the skull. The physician exposes the aneurysm and places a metal clip across the neck of the aneurysm to prevent blood flow into the aneurysm sac. Once the clipping is completed, the skull is sutured back together.

endovascular coiling or coil embolization Endovascular coiling is a minimally invasive technique, which means an incision in the skull is not required to treat the cerebral aneurysm. Rather, a catheter is advanced from a blood vessel in the groin up into the blood vessels in the brain. Fluoroscopy (a special type of x-ray, similar to an xray "movie") will be used to assist in advancing the catheter to the head and into the aneurysm. Once the catheter is in place, very tiny platinum coils are advanced through the catheter into the aneurysm. These tiny, soft, platinum coils, which are visible on x-ray, conform to the shape of the aneurysm. The coiled aneurysm becomes clotted off (embolization), preventing rupture. This procedure is performed either under general or local anesthesia.

Developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia is a common disorder affecting infants and young children. The change in name reflects the fact that DDH is a developmental process that occurs over time. It develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth.

In this condition there is a disruption in the normal relationship between the head of the femur and the acetabulum (hip socket). DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called subluxation.

The hip joint is where the femur (thighbone) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball and socket joint is what allows us to move our leg in many directions in relation to the body.

The right amount of pressure and contact between the surfaces of these two parts helps make sure the hip joint develops normally. Most of the acetabulum is cartilage at birth. The head of the femur inside the acetabulum helps shape the joint as it continues to form. In DDH the usual contact between the femoral head and the acetabulum is disrupted.

An abnormal position of the femoral head can result in a dysplastic hip. Sometimes the acetabulum is too shallow or sloping rather than a normal cup shape. It cannot hold the femoral head in place. If the problem is not diagnosed and treated early, the soft tissues around the hip start to stretch out. There can be changes in the blood supply to the hip. Sometimes the hip joint tries to form another hip socket called a false acetabulum. Without the proper ligaments, soft tissues, and joint capsule to hold the femoral head in place, the false acetabulum creates even more problems.

Symptoms

The newborn, infant, or young child may not have any symptoms such as pain to signal a problem. There may be some differences in how the legs and buttocks look from side to side. Sometimes the problem isn't noticed until the child starts to walk. If only one hip is affected, the child may walk with a limp. If DDH is present in both hips, the child may sway from side to side or waddle. When both hips are dislocated, it is sometimes very difficult to see an abnormality in the way the child walks.

Treatment


The goal of treatment is to keep the femoral head in good contact with the acetabulum. A stable hip encourages the development of a normally shaped socket and rounded head of the femur. The proper hip position must be maintained for enough time to stabilize the joint. The hip should be flexed to 95 degrees and abducted (apart) at least 90 degrees. This position keeps the ball (the femoral head) in the best position and allows the ligaments and joint capsule to tighten up.

Nonsurgical Treatment

Surgery

An operation called derotational osteotomy may be needed. In this surgical procedure, the femur is cut and rotated to make it easier to keep the femoral head inside the acetabulum. When this procedure is done, the soft tissues loosen up and the forces of the muscles tend to keep the femoral head reduced. Once again, the child is put in a spica cast for several months while the bone heals. A CT scan may be used to confirm successful reduction before removing the cast. A CT scan is a special type of xray that takes slices of the body. This allows a much better picture of the hip and acetabulum than plain x-rays.

What is scoliosis?


Scoliosis is a deformity in the spine that causes an abnormal C-shaped (one curve) or Sshaped curvature (two curves). The spine is not straight but curves to one or both sides.

Congenital
This type of scoliosis occurs in one out of 1,000 live births. It is often caused by one of the following:
   

failure of the vertebrae to form normally absence of vertebrae partially formed vertebrae Lack of separation of the vertebrae

 Neuromuscular

This type of scoliosis is associated with many neurological conditions, especially in those children who do not walk, such as the following:
     

cerebral palsy spina bifida muscular dystrophy paralytic conditions spinal cord tumors neurofibromatosis - a genetic condition that affects the peripheral nerves that causes changes to occur in the skin, called caf-au-lait spots.

Idiopathic
The cause of this type of scoliosis is unknown. There are three types of idiopathic scoliosis:
 

Infantile occurs from birth to three years of age. Juvenile scoliosis develops between four and nine years of age. Adolescent presents between 10 years and when growth is complete. Adults can have residuals of childhood scoliosis.

Other causes of scoliosis may include:

    

hereditary conditions that tend to run in families differences in leg lengths injury infection tumors

What are the symptoms of scoliosis?

 

  

difference in shoulder height the head is not centered with the rest of the body difference in hip height or position difference in shoulder blade height or position when standing straight, difference in the way the arms hang beside the body when bending forward, the sides of the back appear different in height

Treatment of scoliosis:


The goal of treatment is to stop the progression of the curve and prevent deformity. Treatment may include:  observation and repeated examinations Observation and repeated examinations may be necessary to determine if the spine is continuing to curve. Progression of the curve depends upon the amount of skeletal growth, or the skeletal maturity of the child. Curve progression slows down or stops after the child reaches puberty.  bracing Bracing may be used when the curve measures between 25 to 40 degrees on an x-ray, but skeletal growth remains. The type of brace and the amount of time spent in the brace will depend on your child's condition.  surgery Surgery may be recommended when the curve measures 50 degrees or more on an x-ray and bracing is not successful in slowing down the progression of the curve.

One type of treatment for scoliosis is the use of a brace. The brace works by exerting pressure on the back and ribs to push the spine in a straighter position. The brace usually fits snugly around the torso and can come in many styles. In a child who is still growing, bracing is usually recommended to help slow the progression of the curve. The brace is usually worn full-time until the growth of the bones has stopped.

Surgery


If bracing doesn't stop the progression of scoliosis, then surgery may be needed. Metal rods or screws are used to help straighten and hold the spine in a corrected position. The vertebra are fused (joined together) to help correct the curvature. Only a small number of people with scoliosis require surgical intervention. New surgical techniques are designed to give maximum correction with a minimum of incisions and scarring.

What is Kyphosis?


Kyphosis is a curving of the spine that causes a bowing of the back, such that the apex of the angle points backwards leading to a hunchback or slouching posture.

Postural Kyphosis


Postural kyphosis-sometimes called round back-is the result of poor posture. This condition is most common in adolescents and young adults. Slouching when standing or sitting causes the spine to curve forward. Postural kyphosis is often accompanied by hyperlordosis of the lumbar (lower) spine. The lumbar spine naturally has a lordosis or inward curve. Hyperlordosis means the lumbar spine compensates for too much thoracic kyphosis by curving too far in the inward direction.

A postural kyphosis corrects itself when lying down on a flat surface, or when the spine is hyperextended. There are no noticeable vertebral abnormalities on X-rays because structural damage or deformity does not cause this kyphosis. Postural kyphosis is easily corrected with education about proper posture, including some retraining on how to sit and stand correctly. Special bracing or casting is usually not necessary. Strengthening exercises for the back muscles can be helpful in correcting posture.

Scheuermanns Kyphosis


Scheuermanns kyphosis affects the shape of the vertebral bodies in the mid back. The front of several vertebral bodies becomes narrow. The affected bones appear wedge-shaped, producing forward rounding (kyphosis) in the thoracic spine.Researchers are unsure what causes Scheuermanns kyphosis. Genetics appear to have a role, meaning it runs in families. Spine specialists suspect the problem may have to do with damage in the area where growth occurs in the vertebral body. Others suggest mild osteoporosis or muscle abnormalities could contribute to the deformi

Congenital Kyphosis


Congenital kyphosis means a person is born with some sort of defect, such as incomplete formation of the spine. This can lead to a severe abnormal kyphosis.

Severe congenital kyphosis deformities are usually treated surgically. Conservative treatment plans are less successful at correcting this type of kyphosis. Early surgical intervention generally produces the best results and can prevent progression of the curve. The type of surgical procedure will depend on the nature of the abnormality. If nonsurgical treatment is chosen, there is a critical need for observation and close medical follow-up to prevent possible problems later.

Paralytic Disorders


Conditions that cause paralysis can lead to kyphosis. Paralysis can be caused by disorders such as Polio, muscular dystrophy, and Cerebral Palsy (paralysis caused by trauma at birth or developmental defects in the brain). The development of kyphosis in these cases is gradual rather than sudden.

Post-Traumatic Kyphosis


Injury to the spine can lead to progressive kyphosis and nerve problems in the spine. A vertebral fracture in the thoracic or lumbar spine will almost always cause some degree of kyphosis. Post-traumatic kyphosis is sometimes treated with either bracing or surgery. The choice will depend on the severity of the condition.

Post-Surgical Kyphosis


Kyphosis can develop after spine surgery has been done to correct other problems. This usually occurs when the procedure does not heal as intended. For example, a spine fusion may not heal, and the unstable fusion may cause the spine to collapse into kyphosis. The ligaments of the spine may not heal strongly enough to support the vertebrae, and a kyphosis develops. A second operation might be needed.

Degenerative Kyphosis


There are cases of kyphosis that are caused by degeneration (wear and tear of the spine). Over time, the degenerative process can result in collapse of the intervertebral disc, changes in the shape of the vertebrae, and weakening of the ligaments that support the spine. This can result in the gradual development of a kyphosis over many years. Once the kyphosis begins to form, it gets worse because the imbalance of the forces continually increases the wear and tear.

Kyphosis Treatment


Non-surgical Treatment Non-surgical treatments are chosen first whenever possible and commonly include medications, exercise, and certain types of braces to support the spine.


If osteoporosis is present, treatment of the condition may also slow the progression of the degenerative kyphosis. This can be accomplished in several ways. The current recommendations include increasing calcium and vitamin D intake, hormone replacement therapy, and weightbearing exercises.

Physical Therapy Adolescents and adults with kyphosis may work with a physical therapist. A wellrounded rehabilitation program assists in calming pain and inflammation, improving mobility and strength, and helping you do your daily activities with greater ease and ability.


Exercise has not proven helpful for changing the kyphotic curve in the back. However, it can be helpful in providing pain relief. Therapy sessions may be scheduled two to three times each week for up to six weeks. The goals of physical therapy are to help you learn correct posture and body movements to counteract the effects of kyphosis, maintain appropriate activity levels, maximize your range of motion and strength and learn ways to manage your condition.

Bracing


Bracing is the standard treatment to control curve progression in adolescents if the patient is still growing and the curve is likely to get bigger. It is important that the patient wear the brace daily for the number of hours prescribed by the doctor. A spinal brace may provide some pain relief. In adults, it will not cause the spine to straighten. Once you have reached skeletal maturity, bracing is used for pain relief rather than prevention.

Surgical Treatment


The most common reason for kyphosis surgery is pain relief for chronic discomfort that keeps getting worse. Most cases of adult kyphosis surgeries are done to relieve severe pain. However, if the pain is manageable through conservative treatments, surgery will probably not be recommended. Progression of the kyphosis deformity is another reason for considering surgery. If the curvature continues to worsen, surgery may be suggested. Surgery is recommended in this situation to prevent the problems that come from severe kyphosis.

The goals of most surgical procedures for adult kyphosis are to:


 

reduce the deformity (straighten the spine as much as possible) stop the progression of the deformity remove any pressure from the nerves and spinal cord protect the nerves and spinal cord from further damage

What is Lordosis?


Lordosis is an exaggerated inward curvature of the spine, particularly in the lumbar region, and can also occur in the neck.

What causes lordosis?



The cause of lordosis is unknown. However, lordosis may be associated with poor posture, a congenital (present at birth) problem with the vertebrae, neuromuscular problems, back surgery, or a hip problem.

Symptoms


Each child may experience symptoms differently. The major clinical feature of lordosis is a prominence of the buttocks. Symptoms will vary depending if lordosis occurs with other defects, such as muscular dystrophy, developmental dysplasia of the hip, or neuromuscular disorders. Back pain, pain down the legs, and changes in bowel and bladder habits are not commonly associated with lordosis. A child experiencing these types of symptoms requires further medical evaluation by a physician. The symptoms of lordosis may resemble other spinal conditions or deformities, or may be a result of an injury or infection.

Treatment


Lordosis generally does not cause any discomfort or serious problems and often does not require any special treatment. However, in case of excessive lordosis, the curvature may lead to severe pain in the lower back and needs to be treated. Diagnostic procedures of lordosis include Xrays, magnetic resonance imaging, bone scans, computed tomography scan and blood tests.

Non Surgical treatment



The non surgical conservative treatments may include pain management drugs, like analgesics or anti inflammatory medications, physical therapy including some specific lordosis exercises program, back bracing and reduction of body weight. Lordosis exercises include stretching of the overactive muscles like the hip flexors and strengthening the abs and hip extensors. One could go for stiff leg deadlifts, low bar squats or glute hamstring raises. The progression of the skeletal curve is checked frequently during the course of treatment in order to prevent the deformity.

Surgical Treatment


A spine surgery may be required when all the non surgical treatments fail to provide relief. There can be different surgical procedures involved for lordosis depending on the type and intensity of the curvature. Spinal fusion is a type of corrective surgery which is often recommended in case of extreme lordosis. A specific diet and a daily exercise plan may be prescribed after the surgery for effective recovery.

Genu valgum


Knock-knees (or genu valgum) is a condition where the legs are bowed inwards in the standing position. The bowing usually occurs at or around the knee, so that on standing with the knees together, the feet are far apart.

Genu Varum


Bowlegs (or genu varum) is a condition where the legs are bowed outwards in the standing position. The bowing usually occurs at or around the knee, so that on standing with the feet together, the knees are far apart.

Causes


Most people have some degree of bowleg or knockknee and is considered within the limits of normal structure and function. During development in the first few years of life, because of rapid and differential growth around the knees,
  

most children are bowlegged from birth till age 3, then become knock-kneed till age 5, then straighten up by age 6 or 7.

In most children, even as they grow through these phases, the bowleg and knock-knee are not severe, and do not engender concern on the part of the parents. In some instances, the bowleg or knock-knee gets quite obvious, and becomes worrisome for the parents.

There are, of course, more serious causes of bowlegs and knock-knees. They include the following:


Blounts disease - a condition of severe bowleg that occurs usually in black children that is progressive, and may require surgery. Growth disturbance - or epiphyseal dysplasia, which may be a part of a generalized bone growth disturbance. Post-trauma - where injury to the knee causes damage to the growth plate (also called the epiphyseal plate) and abnormal growth around the knee. Rickets- Lack of vitamin D intake, or inability to metabolize Vitamin D due to kidney disease can cause growth disturbance of the bones in the body, including the knee.

Genu Recurvatum


The backward curvature of the knee; hyperextension of the knee. a deformity in which the lower leg is hyperextended at the knee joint. Also called back knee.

Pes Cavus


Pes clavus (clawfoot) refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum of the foot.

Causes


 

Charcot-Marie-Tooth Disease (peripheral neurumuscular disease associated with familial degenerative disorder Diabetes mellitus Tertiary syphilis

Treatment


 

Exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes Bracing to protect the foot In severe cases, arthrodesis (fusion) is performed to reshape and stabilize the foot.

Pes Planus


Flatfoot (Pes Flanus) is a common disorder in which the longitudinal arch of the foot is diminished.

Contusions


A contusion is a soft tissue injury produced by blunt force, such as a blow, kick or fall Many small blood vessels rupture and bleed into soft tissues (ecchymosis, or bruising) A hematoma develops when the bleeding is sufficient to cause an appreciable collection of blood Local symptoms (pain, swelling, and discoloration) are controlled with intermittent aplication of cold packs. Most contusions resolve in 1 to 2 weeks

Strain


Strain or a pulled muscle is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress

Types of strain


A first degree strain reflects tearing of few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. A second-degree strain involves tearing of more muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm and ecchymosis A third-degree strain is the most severe type and involves complete disruption of at least one musculotendinous unit that involves separation of muscle from muscle, muscle from tendon, or tendon from bone. A patient with this type of strain presents with significant pain, muscle spasm, ecchymosis, edema, and loss of function

Sprain
     

Sprain is an injury to the ligaments and supporting muscle fibers that surround a joint. It is caused by a wrenching or twisting motion. The function of a ligament is to stabilize the articulating bones of a joint while permitting mobility. A torn ligament loses its stabilizing ability Blood vessels rupture and edema occurs; the joint is tender, and movement of the joint becomes painful. The degree of disability and pain increases during the first 2 to 3 hours after the injury because of the associated swelling and bleeding.

Types of Sprain


A first-degree sprain is caused by tearing of a few ligamentous fibers. It is manifested by mild edema, local tenderness, and pain that is elicited when the joint is moved; however, there is appreciable joint stability. A second-degree sprain involves tearing of more fibers. It results in increased edema, tenderness, pain with motion, joint stability, and partial loss of normal joint function. A third-degree sprain occurs when a ligament is completely torn. It is manifested by severe pain, tenderness, increased edema, and abnormal joint function.

Management
 

Rest prevents additional injury and

promotes healing. Ice intermittent application of moist or dry cold packs for 20 to 30 minutes during the first 24 to 48 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort Compression an elastic compression bandage controls bleeding, reduces edema, and provides support for the injured tissues. Elevation controls the swelling.

If the strain or sprain is 3rd-degree, surgical repair or immobilization by cast may be necessary so that the joint will not lose its stability. The neuromuscular status (circulation, motion, sensation) of the injured extremity is monitored frequently. After the acute inflammatory stage (eg 24 to 48 hrs after injury), heat may be applied intermittently (for 15 to 30 minutes, four times a day) to relieve muscle spasm and to promote vasodilation, absorption, and repair. Depending on the severity of injury, progressive passive and active exercises may begin in 2 to 5 days. Severe sprains and strains may require 1 to 3 weeks of immobilization before exercises are initiated.

Causes
      

Congenital abnormalities Bone or ligament injury Muscle and posture imbalances Excessive weight Muscle fatigue Poorly fitting shoes arthritis

Symptoms
    

Burning sensation Fatigue Clumsy gait Edema pain

treatment


Exercises to strengthen the muscles and to improve posture and walking habits Foot orthoses are available to give the foot additional support.

Fracture


. A fracture is a break in the continuity of the bone.

Common fracture sites:

 

  

Clavicle Humerus In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site. Radius and ulna Femur (often associated with child abuse) Epiphyseal plates (potential for growth deformity)

Types of Fracture
 

    

Closed or simple fracture The bone is broken, but the skin is not lacerated. Open or compound fracture -The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. Transverse fracture The fracture is at right angles to the long axis of the bone. Greenstick fracture - Fracture on one side of the bone, causing a bend on the other side of the bone. Comminuted fracture - A fracture that results in three or more bone fragments. Oblique Fracture The fracture is diagonal to a bones long axis. Spiral Fracture At least one part of the bone has been twisted.

Complications of fractures include:



     

problems associated with immobility (muscle atrophy, joint contracture, pressure sores) growth problems ( in children) infection shock venous stasis and thromboembolism pulmonary emboli and fat emboli and bone union problems

Etiology


Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries.

Pathophysiology


Fractures occur when the resistance of bone against the stress being exerted yields to the stress force. Fractures most commonly seen in children:


Bend Fracture is characterized by the bone bending to the breaking point and not straightening without intervention. Buckle fracture results from compression failure of the bone, with the bone telescoping on itself. Greenstick fracture is an incomplete fracture.

Assessment Findings


Clinical Manifestations


The five Ps pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures. Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children).

Laboratory and diagnostic findings



Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity. Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD).

Nursing Management
         

Provide emergency management when situation warrants, for a new fracture. Assess the five Ps. Determine the mechanism of injury. Immobilize the part. Move injured parts as little as possible. Cover any open wounds with a sterile, or clean dressing. Reassess the five Ps. Apply traction if circulatory compromise is present. Elevate the injured limb, if possible. Apply cold to the injured area. Call emergency medical services.

 

Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). Administer analgesic medications. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care.

 

Prevent Complications Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage.
 

Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery. Treatment entails pressure relief, which sometimes require performing a fasciotomy.

Prevent infection, including osteomyelitits, bys using infection control measures. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.

Tuberculosis of the Backbone



Pott's Disease


Tuberculosis (TB) of the backbone is not common, but is still seen in poor communities, especially in children. It is the most common form of tuberculosis of the bone. It is important to recognize and treat it early, before damage to the backbone causes nerve damage and paralysis.

a child begins to develop a sharp bend in the middle section of the backbone, with shortening and thickening of the chest, it is probably tuberculosis of the spine.You can almost be sure it is, if someone in the family has TB of the lungs.

If

As the spine collapses forward, the child may have to hold himself up using his arms. Seek medical help quickly. Skin test, Xrays (of the chest and spine), and microscope examination of pus from abscesses (pockets of pus) may help in the diagnosis. If the X-ray shows typical bone destruction, the child should be treated for tuberculosis even if no TB germs are found.

SIGNS


It begins little by littleoften without pain at first. A bump develops in the backbone. This is because the front part of one or more vertebrae is destroyed and collapses.

   

 

The child has trouble bending over to pick things up. An abscess full of pus may form near the lump in the spine. It may open lower on the body and drain pus. As the condition gets worse, back pain may begin. Signs of spinal cord injury may develop: pain, numbness, weakness or paralysis in feet and legs, and loss of urine and bowel control. TB skin test is usually positive. (However, the skin test is of use only if the child has not been vaccinated against TB.) Often someone in the home has TB. Only half of children with TB of the spine also have TB of the lungs.

Treatment


Use 2 to 3 TB medicines for at least a year, as for TB of the lungs. A back brace may help keep the damaged spine straighter. It can be made of plaster, or of plastic using techniques similar to those used for making plastic leg braces

Rheumatoid arthritis (often called RA) is a chronic (long-standing) disease that damages the joints of the body.

What is rheumatoid arthritis?

  

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body tissues are mistakenly attacked by its own immune system. Because it can affect multiple organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. Typically, however, rheumatoid arthritis is a progressive illness that has the potential to cause joint destruction and functional disability.

Rheumatoid arthritis affects approximately 1.3 million people in the U.S., with women developing the condition three times more than men.

Who is at risk for rheumatoid arthritis?



   

Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.

Juvenile rheumatoid arthritis (JRA) causes joint inflammation and stiffness for more than six weeks in a child aged 16 or younger.

What is juvenile rheumatoid arthritis?



Juvenile rheumatoid arthritis (JRA) is arthritis that causes joint inflammation and stiffness for more than six weeks in a child aged 16 or younger. It affects approximately 50,000 children in the United States. Inflammation causes redness, swelling, warmth, and soreness in the joints, although many children with JRA do not complain of joint pain. Any joint can be affected, and inflammation may limit the mobility of affected joints.

An example showing the differences between a normal, healthy joint, a joint affected by osteoarthritis, and one affected by rheumatoid arthritis

What is the difference between normal, healthy joints and arthritic joints?
   

A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles. In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and progress as the individual ages.

Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, the cause of rheumatoid arthritis is unknown.

What causes rheumatoid arthritis?



 

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues; resulting in inflammation in various organs of the body such as the lungs or eyes. Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation.
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation.

Remission, relapse, and flares

  

  

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission).  Remissions can occur spontaneously or with treatment and can last weeks, months, or years.  During remissions, symptoms of the disease disappear and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.

Rheumatoid arthritis symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness.

What are the symptoms of rheumatoid arthritis?



When the disease is active, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender.


This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).

In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body are affected).

What are the symptoms of rheumatoid arthritis? (cont.)



 

 

In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. The small joints of the feet are also commonly involved. Chronic inflammation can cause damage to body tissues, cartilage, and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function.

Rheumatoid arthritis is a systemic disease and its inflammation can affect organs and areas of the body other than the joints.

Rheumatoid arthritis and inflammation of organs



Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Examples of other areas that may be affected include:  Sjogren's syndrome is inflammation of the glands of the eyes and mouth and causes dryness of these areas.  Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing.  Tissue inflammation surrounding the heart, called pericarditis, can cause chest pain that typically changes in intensity when lying down or leaning forward.  Rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells.  Decreased white cells can be associated with an enlarged spleen (Felty's syndrome) and can increase the risk of infections.  Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure.  A rare and serious complication is blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

A rheumatologist is a medical doctor who specializes in the non-surgical treatment of rheumatic illnesses, especially arthritis.

Who is a rheumatologist?
 

 

A rheumatologist is a medical doctor who specializes in the nonsurgical treatment of rheumatic illnesses, especially arthritis. Rheumatologists have special interests in unexplained rash, fever, arthritis, anemia, weakness, weight loss, fatigue, joint or muscle pain, autoimmune disease, and anorexia. They often serve as consultants, acting like detectives for other doctors. Rheumatologists have particular skills in the evaluation of the over 100 forms of arthritis, and have special interest in rheumatoid arthritis, spondylitis, psoriatic arthritis, systemic lupus erythematosus, antiphospholipid syndrome, Still disease, dermatomyositis, Sjogren's syndrome, vasculitis, scleroderma, mixed connective tissue disease, sarcoidosis, Lyme disease, osteomyelitis, osteoarthritis, back pain, gout, pseudogout, relapsing polychondritis, Henoch- Schonlein purpura, serum sickness, reactive arthritis, Kawasaki disease, fibromyalgia, erythromelalgia, Raynaud's disease, growing pains, iritis, osteoporosis, reflex sympathetic dystrophy, and others.

The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient.

How is rheumatoid arthritis diagnosed?



    

The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and patient. A doctor with special training in arthritis and related diseases is called a rheumatologist. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult.

A newer, more specific blood test for rheumatoid arthritis is the citrulline antibody test.

RA diagnostic test: citrulline antibody test



Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called "rheumatoid factor" can be found in 80% of patients. Citrulline antibody is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in detecting the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies are also indicators of potentially more aggressive disease. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.

Another blood test for RA called the sedimentation rate (sed rate), is a measure of how fast red blood cells fall to the bottom of a test tube.

RA diagnostic test: sedimentation rate (sed rate)



  

A blood test called the sedimentation rate (sed rate), is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.

Joint X-rays can also be helpful in monitoring the progression of rheumatoid disease and joint damage over time.

RA diagnostic test: joint X-rays

 

Joint X-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses, X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, and MRI scanning can demonstrate inflamed or eroded joints.

In arthrocentesis, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory.

RA diagnostic test: arthrocentesis

 

  

The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain fluid out of the joint for study in the laboratory. Analysis of the joint fluid can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.

There is no known cure for rheumatoid arthritis; however, early medical intervention has been shown to be important in improving outcomes.

How is rheumatoid arthritis treated?

 

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is
  

to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity.

  

Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs."

What medications are used to treat rheumatoid arthritis?



 

Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold (Solganal), methotrexate (Rheumatrex, Trexall), and hydroxychloroquine (Plaquenil) promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents. Some newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).

Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol and others) or OTC topical preparations.

Other treatments for rheumatoid arthritis



 

There is no special diet for rheumatoid arthritis. Fish oil may have antiinflammatory beneficial effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol and others) or over-the-counter (OTC) topical preparations, which are rubbed into the skin.

The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually.

Other treatments for rheumatoid arthritis (cont.)



The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome can be helped by artificial tears and humidifying rooms in the home or office. Medicated eye drops, cortisporine ophthalmic drops (Restasis), are also available to help the dry eyes in those affected. Regular eye check-ups and early antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis), bursae (bursitis), and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.

A balance of rest and exercise is important in treating rheumatoid arthritis.

Why is rest and exercise important?



  

 

A balance of rest and exercise is important in treating rheumatoid arthritis. During flare-ups (worsening of joint inflammation), it is best to rest the joints that are inflamed. When joint inflammation is decreased, guided exercise programs are necessary to maintain flexibility of the joints and to strengthen the muscles that surround the joints. Range-of-motion exercises should be done regularly to maintain joint mobility. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications can ease symptoms before and after exercise.

Surgery may be an option to restore joint mobility, repair damaged joints, or in worst case scenarios, total artificial joint replacement.

Is surgery an option for rheumatoid arthritis?



Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy (insertion of a tube-like instrument into the joint to see and repair abnormal tissues) to partial and complete replacement of the joint. Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial materials.
 

For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals.

Osteoarthritis: What Is It?



Also called "wear and tear" arthritis or degenerative joint disease, osteoarthritis (OA) is the progressive breakdown of the joints' natural shock absorbers. This can cause discomfort when you use the affected joints perhaps an ache when you bend at the hips or knees, or sore fingers when you type. Most people over 60 have some degree of OA, but it also affects people in their 20s and 30s.

Osteoarthritis: Symptoms


 

The symptoms of osteoarthritis tend to develop slowly. May notice pain or soreness when moving certain joints or when inactive for a prolonged period. The affected joints may also be stiff or creaky. Typically, osteoarthritis leads to morning stiffness that resolves in 30 minutes. When osteoarthritis affects the hands, some people develop bony enlargements in the fingers, which may or may not cause pain.

Osteoarthritis: Where Does It Hurt?

In most cases, osteoarthritis develops in the weight-bearing joints of the knees, hips, or spine. It's also common in the fingers, thumb, neck, and big toe.

Osteoarthritis: What Causes It?



Every joint comes with a natural shock absorber in the form of cartilage. This firm, rubbery material cushions the ends of the bones and reduces friction in healthy joints. As we age, joints become stiffer and cartilage is more vulnerable to wear and tear. At the same time, repetitive use of the joints over the years irritates the cartilage. If it deteriorates enough, bone rubs against bone, causing pain and reducing range of motion.

Risk Factors You Can't Control



One of the major risk factors for osteoarthritis is something none of us can control getting older. Gender also plays a role. Over age 50, more women than men develop osteoarthritis. In most cases, the condition results from normal wear and tear over the years. But some people have a genetic defect or joint abnormality that makes them more vulnerable.

Risk Factors You Can Control



Because injured joints are more vulnerable to osteoarthritis, doing anything that damages the joints can raise your risk. This includes sports that have a high rate of injury and jobs that require repetitive motion, such as bending the knees to install flooring. Obesity is another risk factor it has been linked specifically to osteoarthritis of the knees and hips.

Impact on Daily Life



Osteoarthritis affects each person differently. Some people have few symptoms despite the deterioration of their joints. Others experience pain and stiffness that may interfere with daily activities. If bony knobs develop in the small joints of the fingers, tasks such as buttoning a shirt can become difficult. Osteoarthritis of the knees or hips can lead to a limp. And osteoarthritis of the spine can cause debilitating pain and/or numbness.

Diagnosing Osteoarthritis


 

History: symptoms, location and frequency of pain X-rays or other imaging studies Blood tests (to rule out other forms of arthritis

Long-Term Complications


Unlike rheumatoid arthritis, osteoarthritis does not affect the body's organs or cause illness. But it can lead to deformities that take a toll on mobility. Severe loss of cartilage in the knee joints can cause the knees to curve out, creating a bowlegged appearance (shown on the left). Bony spurs along the spine (shown on the right) can irritate nerves, leading to pain, numbness, or tingling in some parts of the body.

Treatment: Physical Therapy



There is no treatment to stop the erosion of cartilage in the joints, but there are ways to improve joint function. One of these is physical therapy to increase flexibility and strengthen the muscles around the affected joints. The therapist may also apply hot or cold therapies such as compresses to relieve pain.

Supportive Devices


Supportive devices, such as finger splints or knee braces, can reduce stress on the joints and ease pain. If walking is difficult, canes, crutches, or walkers may be helpful. People with osteoarthritis of the spine may benefit from switching to a firmer mattress and wearing a back brace or neck collar.

Medication for OA


When osteoarthritis flares up, many patients find relief with over-the-counter pain and antiinflammatory medication, such as aspirin, ibuprofen, or acetaminophen. Pain-relieving creams or sprays can also help when applied directly to the sore area. If pain persists despite the use of pills or creams, the doctor may suggest an injection of steroids or hyaluronans directly into the joint.

Osteoarthritis and Weight



If you're overweight, one of the most effective ways to relieve pain in the knee or hip joints is to shed a few pounds. Even modest weight loss has been shown to reduce symptoms of osteoarthritis by easing the strain on weightbearing joints. Losing weight not only cuts down on pain, but may also reduce long-term joint damage.

Osteoarthritis and Exercise



People with osteoarthritis may avoid exercise out of concern that it will cause pain. Low-impact activities such as swimming, walking, or bicycling can improve mobility and increase strength. Training with light weights can help by strengthening the muscles that surround the joints. For example, strengthening the quadriceps can reduce pain in the knees.

Is Surgery for You?



If osteoarthritis interferes significantly with everyday life and the symptoms don't improve with physical therapy or medication, joint replacement surgery is an option. This procedure is used on those with severe OA and replaces a damaged joint with an artificial one. The knee and hip are the joints that are replaced most often.

Preventing Osteoarthritis

Preventing Osteoarthritis


  

The most important thing to ward off osteoarthritis is keep weight in check. Over the years, extra weight puts stress on the joints and may even alter the normal joint structure. Preventing injuries is also important. Take precautions to avoid repetitive motion injuries on the job. If playing a sport, use proper equipment and observe safety guidelines.

What Is Osteoporosis?


Osteoporosis is a disease characterized by low bone mass and loss of bone tissue that may lead to weak and fragile bones. If you have osteoporosis, you have an increased risk for fractured bones (broken bones).

Does Osteoporosis Only Affect the Elderly?



Osteoporosis has often been thought to be a condition that frail elderly women develop. However, the damage from osteoporosis begins much earlier in life. Because peak bone density is reached at approximately 25 years of age, it is important to build strong bones by that age, so that the bones will remain strong later in life. Adequate calcium intake and exercise are essential for building strong bones.

Why Is Osteoporosis an Important Public Health Issue?



In the United States, more than 10 million people have osteoporosis and almost 34 million more have low bone density. Approximately 80% of those with osteoporosis are women. Of people older than 50 years of age, one in two women and one in eight men are predicted to have an osteoporosis-related fracture in their lifetime. White and Asian racial groups are at a greater risk. With the aging of America, the number of people with osteoporosisrelated fractures will increase substantially. The pain, suffering, and economic costs will be enormous.

What Are the Symptoms of Osteoporosis?



Normal bone is composed of protein, collagen, and calcium, all of which give bone its strength. Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone to fracture. The osteoporosis condition can be present without any symptoms for decades. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. Symptoms depend on the location of the fracture.

Osteoporosis Symptoms: Fractures of the Spine



Fractures of the spine (vertebra) can cause severe "band-like" pain that radiates around from the back to the side of the body. Over the years, repeated spine fractures can cause chronic lower back pain as well as loss of height or curving of the spine, which gives the individual a hunched-back appearance of the upper back, referred to as a "dowager hump."

Osteoporosis Symptoms: Stress Fracture



A fracture that occurs during the course of normal activity is called a minimal trauma fracture or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Osteoporosis Symptoms: Hip Fracture



Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality

What Are the Consequences of Osteoporosis?

   

Osteoporosis bone fractures are responsible for considerable pain, decreased quality of life, lost workdays, and disability.
  

Up to 30% of patients suffering a hip fracture will require long-term nursing-home care. Some 20% of women with a hip fracture will die in the subsequent year as an indirect result of the fracture. In addition, once a person has experienced a spine fracture due to osteoporosis, he or she is at very high risk of suffering another such fracture in the near future (next few years).

What Factors Determine Bone Strength?

  

 

Bone mass (bone density) is the amount of bone present in the skeletal structure. Generally, the higher the bone density, the stronger the bones. Bone density is greatly influenced by genetic factors and can be affected by environmental factors and medications.  For example, men have a higher bone density than women.  African Americans have a higher bone density than Caucasian or Asian Americans. Normally, bone density accumulates during childhood and reaches a peak by around 25 years of age. Bone density is then maintained for about 10 years. After age 35, both men and women will normally lose 0.3%-0.5% of their bone density per year as part of the aging process.

Menopause, Estrogen, and Osteoporosis

Menopause, Estrogen, and Osteoporosis



Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause, bone loss accelerates. During the first five to 10 years after menopause, women can suffer up to 2%-4% loss of bone density per year! This can result in the loss of up to 25%-30% of their bone density during that time period. Accelerated bone loss after menopause is a major cause of osteoporosis in women.

What Are the Risk Factors for Developing Osteoporosis?

   

     

female gender Caucasian or Asian race thin and small body frames family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture) personal history of fracture as an adult cigarette smoking excessive alcohol consumption lack of exercise diet low in calcium poor nutrition and poor general health

What Are the Risk Factors for Developing Osteoporosis? (continued)

         

malabsorption (nutrients in the bowels are not properly absorbed) low estrogen levels chemotherapy loss of the menstrual period (amenorrhea) chronic inflammation immobility, such as after a stroke or any condition that interferes with walking hyperthyroidism (excessive thyroid hormone) hyperparathyroidism (excessive parathyroid hormone production causes too much calcium to be removed from the bone) vitamin D deficiency (vitamin D helps the body absorb calcium) certain medications can cause osteoporosis such as long-term use of heparin (a blood thinner), antiseizure medications phenytoin (Dilantin) and phenobarbital, and long-term use of oral corticosteroids (such as prednisone)

How Is Osteoporosis Diagnosed?



A routine X-ray can suggest osteoporosis of the bone, which appears much thinner and lighter than normal bones. Unfortunately, by the time X-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, X-rays are not accurate indicators of bone density. The appearance of the bone on the X-ray is often affected by variations in the degree of exposure of the X-ray film. The National Osteoporosis Foundation, the American Medical Association, and other major medical organizations are recommending a dual energy X-ray absorptiometry scan (DEXA or DXA) for diagnosing osteoporosis. The test measures bone density in the hip and the spine, takes only five to 15 minutes to perform, uses very little radiation (less than one-tenth to onehundredth the amount used on a standard chest X-ray), and is quite precise.

Who should have bone density testing?



The National Osteoporosis Foundation guidelines state that there are several groups of people who should consider DXA testing:
  

 

all postmenopausal women below age 65 who have risk factors for osteoporosis; all women aged 65 and older; postmenopausal women with fractures, although this is not mandatory because treatment may well be started regardless of bone density; women with one of the many medical conditions associated with osteoporosis; and women whose decision to use medication might be aided by bone density testing

How Are Bone Density Results Measured?



Upon completion of a DXA scan, the bone density of the patient is then compared to the average peak bone density of young adults of same sex and race. This score is called the "T score," and it expresses the bone density in terms of the number of standard deviations (SD) below peak young adult bone mass. Osteoporosis is defined as a bone density T score of -2.5 SD or below. Osteopenia (between normal and osteoporosis) is defined as a bone density T score between -1 and 2.5 SD. all women aged 65 and older;

How Is Osteoporosis Treated and Prevented?



The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment.

Prevention and Treatment: Exercise



Exercise has a wide variety of beneficial health effects. However, exercise does not bring about substantial increases in bone density. The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved and/or muscle strength is increased. Research has not yet precisely determined what type or duration of exercise is best for osteoporosis. Nevertheless, most doctors recommend weightbearing exercise, such as walking, preferably daily.

A Word of Caution About Exercise



It is important to avoid exercises that can injure already weakened bones. In patients over 40 and those with heart disease, obesity, diabetes mellitus, and high blood pressure, exercise should be prescribed and monitored by their doctors. Finally, extreme levels of exercise (such as marathon running) may not be healthy for the bones. Marathon running in young women that leads to weight loss and loss of menstrual periods can actually cause osteoporosis.

Prevention and Treatment: Quit Smoking and Curtail Alcohol



Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5%-10% of bone mass. Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause. Smoking cigarettes can also lead to earlier menopause. Data on the effect of regular consumption of alcohol and caffeine on osteoporosis is not as clear as with exercise and cigarettes. In fact, research regarding alcohol and caffeine as risk factors for osteoporosis shows widely varying results and is controversial. Certainly, these effects are not as powerful as other factors. Nonetheless, moderation of both alcohol and caffeine is prudent.

Recommended Calcium Intake by the National Institutes of Health Consensus Conference on Osteoporosis

Prevention and Treatment: Calcium Supplements



Building strong and healthy bones requires an adequate dietary intake of calcium and exercise beginning in childhood and adolescence for both sexes. Importantly, once osteoporosis is present, a high dietary calcium intake or taking calcium supplements alone is not sufficient in treating osteoporosis and should not be viewed as an alternative to or substituted for more potent prescription osteoporosis medications. In the first several years after menopause, rapid bone loss can occur even if calcium supplements are taken. Unfortunately, surveys have shown that the average woman in the United States consumes less than 500 milligrams of calcium per day in her diet, less than the recommended amounts. Additional calcium can be obtained by drinking more milk and eating more yogurt or cottage cheese or by taking calcium supplement tablets as well from calcium-fortified foods, such as orange juice.

Prevention and Treatment: CalciumFortified Foods



Excluding dairy products, the average American diet contains approximately 250 mg of calcium. As mentioned on the previous slide, here are some examples of calciumfortified foods and their respective calcium intake.

Prevention and Treatment: Vitamin D



 

     

An adequate calcium intake and adequate body stores of vitamin D are important foundations for maintaining bone density and strength. Unfortunately, vitamin D deficiency is quite common in the United States. Vitamin D is important in several respects: vitamin D helps the absorption of calcium from the intestines; a lack of vitamin D causes calcium-depleted bone (osteomalacia), which further weakens the bones and increases the risk of fractures; and vitamin D, along with adequate calcium (1,200 mg of elemental calcium), has been shown in some studies to increase bone density and decrease fractures in older postmenopausal but not in premenopausal or perimenopausal women. The Food and Nutrition Board of the Institute of Medicine has recommended the following as an as adequate vitamin D intake: 200 IU daily for men and women 19 to 50 years old; 400 IU daily for men and women 51 to 70 years old; and IU daily for men and women 71 years and older. Good sources of vitamin D include natural sunlight, fortified milk, cheese, butter/margarine, cereal, and fish.

Prevention and Treatment: Menopausal Hormone Therapy



Menopausal hormone therapy (previously referred to as hormone replacement therapy or HRT) has been shown to prevent bone loss, increase bone density, and prevent bone fractures. Estrogen is available orally (Premarin, Estrace, Estratest, and others) or as a skin patch (Estraderm, Vivelle, and others). Estrogen is also available in combination with progesterone as pills and patches. Progesterone is routinely given along with estrogen to prevent uterine cancer that might result from estrogen use alone. Women who have had a hysterectomy (surgical removal of the uterus) may take estrogen alone. Due to adverse effects of menopausal hormone therapy, such as increased risks of heart attack, stroke, blood clots in the veins, and breast cancer; menopausal hormone therapy is no longer recommended for long-term use but rather short-term use to relieve menopausal hot flashes. Every woman should have an individualized discussion regarding estrogen replacement with her doctor.

Prevention and Treatment: Medications



Currently, the most effective medications for osteoporosis that are approved by the FDA are anti-resorptive agents, which prevent bone breakdown. Antiresorptive medications inhibit bone removal (resorption), thus tipping the balance in favor of bone rebuilding and increasing bone density. Menopausal estrogen hormone therapy is one example of an antiresorptive agent. Others include alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast). Selective estrogen receptor modulators (SERMs) are a class of drugs that work like estrogen in some tissues. The SERMs are developed to reap the benefits of estrogen while avoiding the potential side effects of estrogen. Examples include tamoxifen and Raloxifene (Evista). For more information on these and other hormone medications, please read the Osteoporosis feature article on MedicineNet.com.

Prevention of Hip Fractures



The FDA has approved hip-protector garments for the prevention of hip fractures in unstable elderly people with known osteoporosis. Brand names available include Hipsaver and Safehip. These can be helpful for selected patients who are in the nursinghome environment, although the real extent of protection against hip fractures that is gained with use of hip protectors is a matter of current controversy.

Osteoporosis At A Glance
   

  

Osteoporosis is a condition of increased susceptibility to fracture due to fragile bone. Osteoporosis weakens bone and increases risk of bone fracture. Bone mass (bone density) decreases after age 35 years and decreases more rapidly in women after menopause. Key risk factors for osteoporosis include genetic factors, lack of exercise, lack of calcium and vitamin D, personal history of fracture as an adult, rheumatoid arthritis, cigarette smoking, excessive alcohol consumption, low body weight, and family history of osteoporosis. Patients with osteoporosis have no symptoms until bone fractures occur. Diagnosis can be suggested by X-rays and confirmed by using tests to measure bone density. Treatments for osteoporosis, in addition to prescription osteoporosis medications, include stopping use of alcohol and cigarettes, and assuring adequate exercise, calcium, and vitamin D.