in2uract

“free” foods

faithful — Sat, 31 Oct 2009 11:32:24 +0000

Foods commonly eaten in the United States:

All of the vegetables and fruits are raw, unless otherwise stated.

The numbers are the grams of available carbohydrate
(that is, carbohydrate minus dietary fiber)
in 100 grams of the portion of the food):

VEGETABLES:

Alfalfa seeds, sprouted 1.28
Arugula 2.05
Asparagus, cooked 2.63
Bamboo shoots, cooked 0.92
Beans, green, cooked 4.69
Beans, snap, green, cooked 4.68
Beet greens, cooked 2.56
Broccoli, cooked 2.16
Brussels sprouts, cooked 4.5
Cabbage, cooked 2.16
Cauliflower, cooked 1.41
Celeriac (celery root), cooked 4.7
Celery 1.95
Chard, swiss, cooked 2.04
Collards, cooked 2.1
Cucumber 1.8
Dandelion greens, cooked 3.5
Eggplant, cooked 4.14
Endive 0.25
Fennel, bulb 4.19
Hearts of palm, canned 2.22
Jicama 3.92
Kale, cooked 3.63
Lettuce, butterhead 1.32
Lettuce, cos or romaine 0.67
Lettuce, iceberg 0.69
Mustard greens, cooked 0.1
Mushrooms 2.94-3.57 (except shitake)
Nopales, cooked 1.27
Olives, canned ripe 3.06
Okra, cooked 4.71
Olives, canned ripe 3.06
Parsley 3.03
Peppers, serano 3.00
Peppers, jalapeno 3.11
Peppers, sweet green 4.63
Peppers, sweet red 4.43
Pumpkin, cooked 3.80
Purslane 3.43
Radicchio 3.58
Radishes 1.99
Rhubarb 2.74
Sauerkraut 1.78
Scallions (green onions) 4.74
Spinach, cooked 1.35
Squash, summer, cooked 2.91
Squash, zucchini, cooked 2.53
Tomatillos 3.93
Tomatoes 3.54
Tomato juice 3.83
Turnips, cooked 2.9
Turnip greens, cooked 0.86
Watercress 0.79

FRUIT:

Avocados 2.39
Chayote (christophene) 2.20
Raspberries 4.77
Strawberries 4.72

NUTS:

Macademia Nuts 4.83
Pecans 4.26

MEAT AND FISH:

All meat and fin fish 0.00
Caviar 4.00
Crab 0.95
Lobster 1.28
Shrimp 0.00

EGGS AND DAIRY:

Butter 0.06
Buttermilk, lowfat 4.79
Cheese, cheddar 1.28
Cheese, Edam 1.43
Cheese, Gouda 2.22
Cheese, Swiss 3.38
Cream cheese, 2.66
Cottage cheese, 2% milkfat 3.63
Eggs 1.22
Half and Half 4.30
Heavy Cream 2.79
Goat milk 4.45
Mayonnaise 2.70
Milk, 1% milkfat, added solids 4.97
Milk, 3.25% milkfat 4.66
Ricotta cheese, whole milk 3.04
Soy milk, 0.51
Yogurt, plain, whole milk 4.66

DIETARY FIBER:

Soluble and insoluble fiber (a part of other foods) 0.00

BEVERAGES:

Coffee (without cream or sugar) 0.00
Diet Soda 0.00
Tea (without milk or sugar) 0.00
Water 0.00

SWEETENERS:

Aspartame (NutraSweet) 0.001
Saccharin (Sweet’N Low) 0.001
Stevia 0.00
Sucralose (Splenda) 0.001

common glycemic index questions

faithful — Fri, 30 Oct 2009 10:53:23 +0000

COMMON GLYCEMIC INDEX QUESTIONS

FOR AN UP-TO-DATE LIST OF EXACT GI VALUES CLICK HERE

What is the difference between glycemic index (GI) and glycemic load (GL)?

Your blood glucose rises and falls when you eat a meal containing carbs. How high it rises and how long it remains high depends on the quality of the carbs (the GI) and the quantity. Glycemic load or GL combines both the quality and quantity of carbohydrate in one ‘number’. It’s the best way to predict blood glucose values of different types and amounts of food. The formula is:

GL = (GI x the amount of carbohydrate) divided by 100.

Let’s take a single apple as an example. It has a GI of 40 and it contains 15 grams of carbohydrate.
GL = 40 x 15/100 = 6 g

What about a small baked potato? Its GI is 80 and it contains 15 g of carbohydrate.
GL = 80 x 15/100 = 12 g

So we can predict that our potato will have twice the metabolic effect of an apple. You can think of GL as the amount of carbohydrate in a food ‘adjusted’ for its glycemic potency.

Should I use GI or GL and does it really matter?

Although the GL concept has been useful in scientific research, it’s the GI that’s proven most helpful to people with diabetes. That’s because a diet with a low GL, unfortunately, can be a ‘mixed bag’, full of healthy low GI carbs in some cases, but low in carbs and full of the wrong sorts of fats such as meat and butter in others. If you choose healthy low GI foods—at least one at each meal—chances are you’ve eating a diet that not only keeps blood glucose ‘on an even keel’, but contains balanced amounts of carbohydrates, fats and proteins.

We suggest that you think of the GI as a tool allowing you to choose one food over another in the same food group—the best bread to choose, the best cereal etc.—and don’t get bogged down with figures. A low GI diet is about eating a wide variety of healthy foods that fuel our bodies best—on the whole these are the less processed and wholesome foods that will provide you with carbs in a slow release form. So what’s the take-home message?

Choose slow carbs, not low carbs
Use the GI to identify your best carbohydrate choices.
Take care with portion size with carb-rich foods such as rice or pasta or noodles to limit the overall GL of your diet.

Do I need to eat only low GI foods at every meal to see a benefit?

No you don’t, because the effect of a low GI food carries over to the next meal, reducing its glycemic impact. This applies to breakfast eaten after a low GI dinner the previous evening or to a lunch eaten after a low GI breakfast. This unexpected beneficial effect is called the “second meal effect”. But don’t take this too far, however. We recommend that you aim for at least one low GI food per meal.

While you will benefit from eating low GI carbs at each meal, this doesn’t have to be at the exclusion of all others. So enjoy baking your own bread or occasional treats. And if you combine high GI bakery products with protein foods and low GI carbs such as fruit or legumes, the overall GI value will be medium.

Why do many high-fibre foods still have a high GI value?

Dietary fibre is not one chemical constituent like fat and protein. It is composed of many different sorts of molecules and can be divided into soluble and insoluble types. Soluble fibre is often viscous (thick and jelly-like) in solution and remains viscous even in the small intestine. For this reason it makes it harder for enzymes to move around and digest the food. Foods with more soluble fibre, like apples, oats, and legumes, therefore have low GI values.

Insoluble fibre, on the other hand, is not viscous and doesn’t slow digestion unless it’s acting like a fence to inhibit access by enzymes (eg. the bran around intact kernels). When insoluble fibre is finely milled, the enzymes have free reign, allowing rapid digestion. Wholemeal bread and white bread have similar GI values. Brown pasta and brown rice have similar values to their white counterparts.

Can I download or can you email me a full list of all GI food values?

Sorry but we have no such list available for download or emailing purposes. Instead, we invite you to search out the foods you are interested in finding on our free GI Database (see the menu link on the left). There you will find a brief explanation on how best to conduct the search. Another option is to purchase our pocket book which is updated annually and contains the latest values at the time of publication: The New Glucose Revolution: Shopper’s Guide to GI Values.

Does the GI increase with serving size? If I eat twice as much, does the GI double?

The GI always remains the same, even if you double the amount of carbohydrate in your meal. This is because the GI is a relative ranking of foods containing the “same amount” of carbohydrate. But if you double the amount of food you eat, you should expect to see a higher blood glucose response – ie, your glucose levels will reach a higher peak and take longer to return to baseline compared with a normal serve.

If testing continued long enough, wouldn’t you expect the areas under the curve to become equal, even for very high and very low GI foods?

Many people make the assumption that since the amount of carbohydrate in the foods is the same, then the areas under the curve will finally be the same. This is not the case because the body is not only absorbing glucose from the gut into the bloodstream, it is also extracting glucose from the blood. Just as a gentle rain can be utilised better by the garden than a sudden deluge, the body can metabolise slowly digested food better than quickly digested carbohydrate. Fast-release carbohydrate causes “flooding” of the system and the body cannot extract the glucose from the blood fast enough. Just as water levels rise quickly after torrential rain, so do glucose levels in the blood. But the same amount of rain falling over a long period can be absorbed into the ground and water levels do not rise.

Why doesn’t the GI of beef, chicken, fish, tofu, eggs, nuts, seeds, avocadoes, many fruits (including berries) and vegetables, wine, beer and spirits appear on the GI database?

These foods contain no carbohydrate, or so little that their GI cannot be tested according to the standard methodology. Bear in mind that the GI is a measure of carbohydrate quality. Essentially, these types of foods, eaten alone, won’t have much effect on your blood glucose levels.

Some vegetables like pumpkin and parsnips appear to have a high GI. Does this mean a person with diabetes should avoid eating them?

Definitely not, because, unlike potatoes and cereal products, these vegetables are very low in carbohydrate. So, despite their high GI, their glycemic load (GI x carb per serve divided by 100) is low. Vegetables contain only small amounts of carbohydrate but loads of micronutrients and should be considered as “free foods”. Eat them all you like!

Can you tell me the GI of alcoholic beverages (beer, wine and spirits)?

Alcoholic beverages contain very little carbohydrate. In fact, most wines and spirits contain virtually none, although beer contains some (3 or 4 grams per 100 mL). A middy of beer (10 ounces) contains about 10 grams of carbohydrate compared with 36 grams in the same volume of soft drink. For this reason, a beer will raise glucose levels slightly. If you drink beer in large volumes (not a great idea) then you could expect it to have a more significant effect on blood glucose. As for enjoying an occasional drink, researchers from the University of Sydney found that a pre-dinner drink tends to produce a ‘priming’ effect, flicking the switch from internal to external sources of fuel and keeping blood-sugar levels low.

Why does some variability occur in the GI for the same food types? For example, Special K cereal shows values from 54 to 84.

The GI database confirms the reproducibility of GI results around the world. White and wholemeal bread, apples, cornflakes, breakfast cereals etc give the same results wherever/whoever tests them. Where there is variability, there are four possible explanations:

Some GI testing groups are not as experienced/accurate as ours. They use venous blood which gives more variability than capillary blood. If we test a product over and over again, we get the same result +/- 5%. That’s as good as nutrient data such as protein, fat, fibre etc.
The variability among different types of potatoes, rices, and oats is REAL. They contain different types of starch (amylose, amylopectin) and that affects the degree of starch gelatinisation. When it comes to sugars like fructose, the concentration of the solution makes a difference to the rate of gastric emptying and therefore the glycemic response. A more dilute solution, say 25 g fructose in 500 mL water will have a higher GI than 25 g fructose in 250 mL. But fructose has a very low GI whichever way you consume it.
Sometimes the manufacturer may change the formulation of their product by reducing the fat content for example. Reducing the fat can increase the GI. Manufacturers may have their products retested if they make significant changes to the formulation, or source ingredients from different suppliers.
Some foods have been tested in people with type 2 diabetes. These values may be higher than that seen in the normal population. Follow the food links in the GI database to find more information on the testing conditions.

Why does pasta have a low GI?

Pasta has a low GI because of the physical entrapment of ungelatinised starch granules in a sponge-like network of protein (gluten) molecules in the pasta dough. Pasta is unique in this regard. As a result, pastas of any shape and size have a fairly low GI (30 to 60). Asian noodles such as hokkein, udon and rice vermicelli also have low to intermediate GI values.

Pasta should be cooked al dente (‘firm to the bite’). And this is the best way to eat pasta – it’s not meant to be soft. It should be slightly firm and offer some resistance when you are chewing it. Overcooking boosts the GI. Although most manufacturers specify a cooking time on the packet, don’t take their word for it. Start testing about 2-3 minutes before the indicated cooking time is up. But watch that glucose load. While al dente pasta is a low GI choice, eating too much will have a marked effect on your blood glucose. A cup of al dente pasta combined with plenty of mixed vegetables and herbs can turn into three cups of a pasta-based meal and fits easily into any adult’s daily diet.

Most breads and potatoes have a high GI. Does this mean I should never eat them?

Potatoes and bread, despite their high GI, can play a major role in a high carb/low fat diet, even if your goal is to reduce the overall GI. Only about half the carbohydrate needs to be exchanged from high to low GI to derive health benefits. Of course, some types of bread and potatoes have a lower GI and these should be preferred in order to lower the GI as much as possible.

The good news for potato lovers is that a potato salad made the day before, tossed with a vinaigrette dressing and kept in the fridge will have a much lower GI than potatoes served steaming hot from the pot. There are a couple of simple reasons for this. The cold storage increases the potatoes’ resistant starch content by more than a third and the acid in the vinaigrette whether you make it with lemon juice, lime juice or vinegar will slow stomach emptying.

What about flour? If I make my own bread (or dumplings, pancakes, muffins etc) which flours, if any, are low GI? What about sprouted grain breads?

To date there are no GI ratings for refined flour whether it’s made from wheat, soy or other grains. This is because The GI rating of a food must be tested physiologically that is in real people. So far we haven’t had volunteers willing to tuck into 50 gram portions of flour on three occasions! What we do know, however, is that bakery products such as scones, cakes, biscuits, donuts and pastries made from highly refined flour whether it’s white or wholemeal are quickly digested and absorbed.

What should you do with your own baking? Try to increase the soluble fibre content by partially substituting flour with oat bran, rice bran or rolled oats and increase the bulkiness of the product with dried fruit, nuts, muesli, All-Bran or unprocessed bran. Don’t think of it as a challenge. It’s an opportunity for some creative cooking.

Bread made from sprouted grains might well have a lower blood-glucose raising ability than bread made from normal flour. When grains begin to sprout, carbohydrates stored in the grain are used as the fuel source for the new shoot. Chances are that the more readily available carbs stored in the wheat grain will be used up first, thereby reducing the amount of carbs in the final product. Furthermore, if the whole kernel form of the wheat grain is retained in the finished product, it will have the desired effect of lowering the blood glucose level.

Some high fat foods have a low GI. Doesn’t this give a falsely favourable impression of that food?

Yes it does, especially if the fat is saturated fat. The GI value of potato chips or french fries is lower than baked potatoes. Large amounts of fat in foods tends to slow the rate of stomach emptying and therefore the rate at which foods are digested. Yet the saturated fat in these foods will contribute to a much increased risk of heart disease. It is important to look at the type of fat in foods rather than avoid it completely. Good fats are found in foods such as avocadoes, nuts and legumes while saturated fats are found in dairy products, cakes and biscuits. We’d all be better off if we left the cakes and biscuits for special occasions.

Why not just adopt a low carbohydrate diet (like the Atkins diet) to keep my blood glucose levels and weight down?

Recent studies show that low carb diets such as the Atkins diet produce faster rates of weight loss than conventional low fat diets. The probable mechanism is lower day-long insulin levels – allowing greater use of fat as the source of fuel – the same mechanism underlying the success of low GI diets. We believe that low carb diets are unnecessarily restrictive (bread, potato, rice, grains and most fruits are restricted) and may spell trouble in the long term if saturated fat takes the place of carbohydrate. Low GI diets strike a happy medium between low fat and low carb diets – you can have your carbs, but must choose them carefully.

Is there a GI plan for nursing mothers?

A low GI diet is ideal while you are breastfeeding. Breastfeeding requires a lot of energy and theoretically this additional energy comes from the body fat laid down during pregnancy. Of course in reality it doesn’t all get used up and most have to make a concerted effort to work off the baby weight. To do this though it is important that you don’t go on a low calorie diet or any sort of extreme measure such as the low carb diets popular in the press. Since breastfeeding tends to increase your appetite (the body’s way of ensuring you have the energy required to produce milk) this is good news as staying on such a diet would be a nightmare! This is what makes the low GI approach so successful – forget about trying to count calories or even your portions of food.

First and foremost focus on the sorts of foods you are eating. Low GI foods are the wholegrains, fresh fruit and vegetables and legumes. By eating these foods as the mainstay of your meals you can trust your appetite and eat to satisfaction while you are breastfeeding. Also get back to some exercise – even if it’s just a daily walk with the pram/carriage. You should then find that the weight slowly starts to shift – realistically give yourself at least that first six months to get back to your pre-pregnancy weight.

How relevant is the GI for athletes?

The GI can be a useful tool to help athletes select the right type of carbohydrates to consume both before and after exercise. Studies have consistently reported that a low GI pre-exercise meal results in a better maintenance of blood glucose concentrations during exercise and a higher rate of fat oxidation. This is likely to result in reduced muscle glycogen utilisation during prolonged exercise and possibly improve endurance performance. Eating high GI meals before exercise may result in plasma glucose concentrations peaking before the onset of exercise and then hypoglycemia occurring within the first 30 minutes of the exercise period. There is little data available on the effect of the GI of carbohydrates eaten before intermittent, power or strength related sports.

During recovery from exercise, muscle glycogen resynthesis is of high metabolic priority. The eating of high GI carbohydrates after exercise increases plasma glucose and insulin concentrations and this facilitates muscle glycogen resynthesis. If however, you are exercising for weight loss purposes or are involved in weight restricted sports, low GI carbohydrates after exercise may be more beneficial as the lower glucose and insulin concentrations will not suppress fat.

I have recently been diagnosed with celiac disease (gluten sensitivity). It’s extremely hard to find both low GI and wheat-free foods. Any suggestions?

This is not as hard as you may think! There are low GI gluten-free foods in four of the five food groups.

Fruit and Vegetables

Temperate climate fruits – apples, pears, citrus (oranges, grapefruit) and stone fruits (peaches, plums, apricots) – all have low GI values. Tropical fruits – pineapple, paw paw, papaya, rockmelon and watermelon tend to have higher GI values, but their glycemic load (GL) is low because they are low in carbohydrate.
Leafy green and salad vegetables have so little carbohydrate that we can’t test their GI. Even in generous serving sizes they will have no effect on your blood glucose levels. Higher carb starchy vegetables include sweet corn (which is actually a cereal grain), potato, sweet potato, taro and yam, so watch the portion sizes with these. Most potatoes tested to date have a high GI, so if you are a big potato eater, try to replace some with lower GI starchy alternatives such as sweet corn, yam or legumes. Pumpkin, carrots, peas, parsnips and beetroot contain some carbohydrate, but a normal serving size contains so little that it won’t raise your blood glucose levels significantly.

Bread and Cereals

Opt for breads made from chickpea or legume based flours. For example chapattis made with besan (chickpea flour) have a low GI. If you make your own bread, try adding buckwheat kernels, rice bran and psyllium husks to lower the GI. Most gluten-free breads seem to be better toasted than used to make sandwiches.
Breakfast cereals containing pysllium husks are likely to have a lower GI – you could also add a teaspoon or two of pysllium to you usual cereal. To date there are just a few gluten-free breakfast cereals on our database that have a low GI. If you do have a higher GI gluten-free cereal, combine it with lots of fruit and low fat yoghurt or low fat milk, to lower the GI.
Noodles are a great stand-by for quick meals, a good source of carbohydrate, provide some protein, B vitamins and minerals and will help to keep blood glucose levels on an even keel. There are several low GI gluten-free options available fresh and dried: buckwheat (soba) noodles; cellophane noodles, also known as Lungkow bean thread noodles or green bean vermicelli, are made from mung bean flour; rice noodles made from ground or pounded rice flour, are available fresh and dried.
Gluten-free pastas based on rice and corn (maize) tend to have moderate to high GI values so opt for pastas made from legumes or soy. As for wholegrains, try buckwheat, quinoa, low GI varieties of rice such as basmati and sweet corn. Currently there are no published values for amaranth, sorghum, and tef. Millet has a high GI.
Minimise refined flour products and starches irrespective of their fat and sugar content such as crispy puffed breakfast cereals, crackers, biscuits, rolls, most breads and cakes or snack foods. Limit high GI snacks such as corn and potato chips, rice cakes, corn thins and rice crackers.

Legumes (pulses) including beans, chickpeas and lentils
When you add legumes to meals and snacks, you reduce the overall GI of your diet because your body digests them slowly. So make the most of beans, chickpeas, lentils, and whole and split dried peas.

Nuts
Although nuts are high in fat (averaging around 50 per cent), it is largely unsaturated, so they make a healthy substitute for foods such as biscuits, cakes, pastries, potato chips and chocolate. They also contain relatively little carbohydrate, so most do not have a GI value. Peanuts (actually a legume) and cashews have very low GI values.

Low fat dairy foods and calcium-enriched soy products
Low fat milk, yoghurt and ice-cream or soy alternatives provide sustained energy, boosting your calcium intake but not your saturated fat intake. Check the labels of yoghurts, icecream and soymilks as many contain wheat-based thickeners. If lactose intolerance is a problem, reach for live cultured yoghurts and lactose-hydrolysed milks. Even ice-cream can be enjoyed if you ingest a few drops of lactase enzyme first.

Is a low GI diet suitable for vegetarians?

The low GI diet is just as easy for a vegetarian to follow – in fact, teaching vegetarians to follow the low GI diet can be easier because most are eating many of the best low GI foods already. For the vegetarian, the same principles apply: substitute your plant protein sources for the meat. Eat more beans, lentils and other legumes – all among the lowest GI foods we have tested. Quorn is also a great meat substitute with no GI as it has almost no carbohydrate (2 g/100 g).

Some additional points:

The GI only applies to foods containing significant amounts of carbohydrate. Most vegetables have small amounts of carbohydrate and those that provide more usually have a low GI, with the exception of potatoes. You can therefore tuck into your veggies without considering the GI for every one – and benefit from antioxidants and all the micronutrients they supply!
Legumes should be a daily part of any vegetarian diet for your protein – happily these are also a mainstay of a low GI diet.
Almost every low GI food we talk about in the book is suitable as part of a vegetarian diet. Animal products are usually high in fat, protein or both and therefore do not have a GI.
The range of protein and carb intake that is healthy is fairly broad – as a vegetarian you will inevitable have a higher carb intake and slightly lower protein intake. This makes the GI important for you but easy to adapt if you choose wholegrain cereal products and legumes as your carbohydrate base.
Coffee has no carbohydrate (unless you add sugar and/or milk and the GI response comes from these foods) and hence it is not in the GI tables. Neither does it contain calories so has little impact on weight control.

100 super foods

faithful — Tue, 27 Oct 2009 11:43:27 +0000

Over 100 Super Foods for a Super You

These foods benefit your body in so many ways. They power your brain, and correctly and efficiently fuel your body. Super foods fight infection, enhance your immune system, and protect against diseases such as osteoporosis, heart disease, certain cancers, diabetes, and respiratory infections.

These foods are not only healthy, but they’re also affordable, familiar, and readily available at regular grocery stores and farmers markets. With so many choices, you’ll discover just how easy it is to eat super healthy every day…even when on a tight budget.

This is an all-inclusive list, but some foods might not be right for your tastes, preferences or health goals. Remember that no single food can provide everything you need to be healthy. That’s why it’s important to choose a variety of super foods from each category to meet your daily nutrition needs.

Vegetables

Asparagus
Avocados
Beets
Bell peppers
Broccoli
Brussels sprouts
Cabbage
Carrots
Cauliflower
Collard greens
Crimini mushrooms
Cucumbers
Eggplant
Garlic
Green beans
Kale
Mustard greens
Onions
Peas
Portobello mushrooms
Potatoes
Rainbow chard
Romaine lettuce
Shiitake mushrooms
Spinach
Summer squash
Sweet potatoes
Swiss chard
Tomatoes
Turnip greens
Winter squash
Yams

Calcium-Rich Foods

Almond milk
Cheese, low fat
Cottage cheese, low fat
Milk, skim or 1%
Orange juice with calcium
Rice milk
Soy milk
Yogurt with active cultures, low fat

Fruits

Apples
Apricots
Bananas
Black olives
Blackberries
Blueberries
Cantaloupe
Cherries
Cranberries
Figs
Grapefruit
Grapes
Honeydew melon
Kiwifruit
Lemons
Limes
Nectarines
Oranges
Papaya
Peaches
Pears
Pineapple
Plums
Prunes
Raisins
Raspberries
Strawberries
Watermelon

Grains

Amaranth
Arborio rice
Barley
Brown rice
Buckwheat
Bulgur
Corn
Jasmine rice
Millet
Oats
Quinoa
Rye
Spelt
Triticale
Wheat berries
Whole grain breads, cereal, pasta
Whole wheat breads, cereal, pasta
Wild Rice

Proteins

Almonds
Beef, lean
Black beans
Cashews
Chicken, skinless
Chickpeas
Egg whites
Eggs
Fish, unbreaded
Flaxseed
Garbanzo beans
Hemp seeds
Hummus
Kidney beans
Lima beans
Lentils
Miso
Navy beans
Nuts
Peanut butter, natural
Peanuts
Pinto beans
Pork, lean
Pumpkin seeds
Salmon, canned or fresh
Seafood, unbreaded
Sesame seeds
Soybeans
Sunflower seeds
Tahini
Tempeh
Tofu
Tuna, canned or fresh
Turkey, skinless
Veggie burgers
Walnuts
Wild game, skinless

Miscellaneous

Canola oil
Dark chocolate
Green tea
Olive oil

adrenal functioning and diet

faithful — Wed, 21 Oct 2009 08:25:48 +0000

are you in an abusive relationship?

faithful — Sun, 18 Oct 2009 13:11:29 +0000

Are You In An Abusive Relationship: 12 Signs It’s Time to Leave

By Norine Dworkin-McDaniel, Special to Lifescript

Published October 18, 2009

Earlier this year, Chris Brown was arrested for assaulting his girlfriend, singer Rihanna, and is now doing community service for his crime. Just last week, “So You Think You Can Dance” judge Mary Murphy revealed that she was in an abusive marriage for years. Are you? In recognition of Domestic Violence Month, read on for 12 signs you’re being abused. Plus, take our quiz to see if you’re in an abusive relationship…

Celebrity abuse scandals make one thing clear: No matter how rich, how successful, how beautiful a woman is, she is not immune to physical abuse.

Even if he never raises a hand, you could be hit with emotional or verbal smackdowns that are equally damaging.

Yet, “women tend to overlook these signs because we’re trying to be understanding, or because we can’t believe that our man would do anything like that,” says Michele Sugg, MSW, a therapist in Branford, Conn.

The number of women who don’t make headlines or get personal pleas from Oprah is staggering: Each year, two million are battered and 1,200 are killed by their partners, according to the Centers for Disease Control and Prevention.

Even more live in fear of violence or face emotional abuse every day.

Check out these 12 signs of abuse, which can help you avoid becoming another statistic:

Signs of Abuse

1. He makes snide jokes at your expense.

Although boorish and rude, the occasional zinger isn’t an automatic ticket to the Abusers Hall of Fame.

But aiming poison barbs in your direction and then brushing it off – like “Can’t you take a joke?” – shows a lack of respect. “It’s a sign of emotional distancing, which can very quickly turn into abuse,” says Gilda Carle, Ph.D., (aka Dr. Gilda), an advice columnist on Match.com and author of He’s Not All That (Collins).

Emotional abuse can become physical with very little notice. Just ask Aimee, 41, of San Francisco, who was in an abusive relationship for eight years – while working at a battered women’s shelter!

It was so subtle, says Aimee (whose name was changed to protect her privacy).

“It went from unhealthy to pathological in such tiny increments that I accepted every little increment completely.”

By the time it crossed over into physical abuse, “I couldn’t name it. I was in absolute denial,” she says.

2. The relationship is on the fast track.

He’s infatuated with you and is already talking commitment. But slow down.

A light-speed lothario often has something to hide, says relationship therapist Joyce Morley-Ball, Ed.D. (aka Dr. Joyce).

If he’s quick to say “I love you” and soon makes plans for moving in, getting married and having a baby, he may be trying to lock up the relationship before you can see what he’s really about.

He knows you’re less likely to leave him after you get involved, she says.

3. Nothing is ever his fault.

That speeding ticket? The cop had it in for him. The job he lost? The boss had a grudge against him. The promotion he didn’t get? The woman who did must have been sleeping with the boss. Maybe your guy has the worst luck ever. Or consider this: The man who never takes responsibility for any of his actions may be quick to blame you when he ultimately loses control of his temper – and his fists. “If you hadn’t done _____, I wouldn’t have hit you.”

If he can get you to believe it’s your fault, he’s off the hook in his mind. So take notice of his blame list – you could be next.

4. You’re always making excuses for his behavior.

He’s tired. He had a hard week. He’s under a lot of pressure. He’s only like that when he’s had too much to drink.

Sure, these excuses may explain the rare social gaffe and could, in fact, be true.

But if you’re regularly trying to explain away rude, violent or disrespectful behavior, you could be emotionally abused.

“There’s this wall of denial that we put up when we’re in a relationship, and we all do it to some extent,” Sugg says. “But you shouldn’t have to explain away someone else’s behavior.”

It’s just like a slap in the face, she says. “How many of those slaps would you take?”

5. You bend over backward so he doesn’t get upset.

Are you walking on eggshells because of his hair-trigger temper that erupts for everything big (a blown business deal) to small (his warm beer)?

But you can’t keep the peace by being perfect because you can’t control his emotions, Dr. Joyce says. “His anger has nothing to do with you and everything to do with him.”

Chances are, no matter how hard you try t make things “perfect” –there’s no such thing, by the way –he’ll still find something that’ll set him off.

“If you’re living in fear of upsetting him because he’ll blow up in your face, undertand that eventually he’ll blow up on your face,” Dr. Gilda says.

6. He controls the money.

It’s one thing if your man is the designated bill-payer (as mutually agreed upon). It’s a different story if you have no access to your personal money, no credit cards in your name and you get only a small allowance. Maybe he even runs up your credit cards, then tanks your credit score.

This is financial abuse, says Brian Namey, spokesman for the National Network to End Domestic Violence (www.nnedv.org). It’s meant to keep you dependent on him.

(To learn more about financial independence, check out the joint venture between NNEDV and AllState Foundation at www.clicktoempower.org.)

7. He doesn’t like your family or friends.

Maybe your mom is a piece of work and your best friend is a teensy bit shallow. But isolating you from people you love and trust until there’s no one left in your life except your guy?

That’s Rule No. 1 in the Abusers Handbook.

When you have no one else to turn to, then he really has you under his thumb.

8. He keeps tabs on what you wear, where you go, who you call…

At first, this may seem loving. If you’re used to emotionally distant guys, the attention he pays will seem wonderful – until you start to suffocate.

All that attention is a way to reel you in so you become dependent on his approval and fear losing it.

“It’s about power and control,” not love, Namey says.

9. He gets in your face when you fight.

All couples fight. But if he comes closer to you during an argument or follows you when you’re trying to walk away, “That’s a sign that he’s so frustrated, he could hit you at any moment,” Dr. Gilda says.

10. He raises his hand (or fist) in anger.

Even if he catches himself before he slaps you, who knows if next time he’ll have such self control?

Denise, 42, of Cleveland, recalls a heated argument with an ex-boyfriend. “It was a stupid discussion about a movie,” says Denise, who requested that her name be changed to protect her privacy.

“All of a sudden his arm flew back,” she says, “and I could see the supreme effort it took him not to smack me. Right then, I knew there’d be a point when he wouldn’t be able to stop himself. I broke up with him the next day.” Pushing, shoving, pinching, hair pulling or other rough treatment is physical abuse. Don’t blow it off.

11. He’s gotten physical – even once.

“Domestic violence is incremental. It escalates,” Dr. Joyce says. “The woman who loses her life probably started with name-calling, a push, a sove, hair pulling or something lke that.”

12. He threatens to kill you.

Believe him and leave. Even if he’s never kept his word before, you don’t want to be there when he decides to follow through.

“When a person is brash enough to make threats, we need to take it at face value,” Dr. Joyce says. “The reality is, if he said it, he probably meant it.”

There are no statistics about how often threats translate into homicide, but Namey says the following situations increase the odds that an abused woman will be killed by her partner:

He has a weapon and has threatened you with it before.
He’s threatened your children.
He’s unemployed.
He’s forced you to have sex.
He’s jealous and controls most of your daily activities.
He says if he can’t have you, nobody can.
He’s threatened or attempted suicide.
You believe he could kill you.

If any of these signs describe your relationship, what’s your next step?

Start by talking to someone you trust, like your girlfriends or family. They have the distance to see red flags in your relationship that you may not.

“If you’re hearing from people that you’re not being treated very well, listen to them and think about that,” Sugg says.

You can even talk about it at your next gynecology visit. In fact, if you feel unsafe in your relationship, ob-gyns hope you’ll talk with them.

“When a woman feels she’s in danger, we can bring her into the hospital, provide a safe zone and help her figure out ways to get out of the relationship,” says ob-gyn Rakhi Dimino, M.D., of Woman’s Hospital of Texas in Houston.

You can also call the National Domestic Violence hotline (available 24/7 in every state) at (800) 799-SAFE (7233) or at (800) 787-3244 for the hearing impaired.

Contrary to its name, it’s not only for physical abuse victims. For emotionally abused women, phone counselors can offer crisis intervention and referrals to other agencies.

Are You in an Abusive Relationship?

An abusive relationship saps your energy, strips away your dignity and can be physically dangerous to you and your family. Are you the victim of abuse? Find out in this abusive relationship quiz.

Check out Health Bistro for more healthy food for thought. See what Lifescript editors are talking about and get the skinny on latest news. Share it with your friends (it’s free to sign up!), and bookmark it so you don’t miss a single juicy post!

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six reasons you can’t leave a loser

faithful — Sun, 11 Oct 2009 13:44:47 +0000

SIX REASONS YOU CAN’T LEAVE HIM

You know he’s not Mr. Right. He’s not even Mr. Right Now. So why can’t a smart woman like you ditch the loser? Read on to find out. Plus, rate your relationship with our quiz…

I was in college when an older man asked me out. We went to a concert (nice), then back to his place (predictable). By morning, I knew the relationship was a non-starter.

But his attention was flattering and I was between boyfriends. Before I knew it, my one-night stand turned into a year-long relationship. He even talked of marriage.

Right then, I should have cut and run. But I’d grown used to his loud, obnoxious behavior. And at least I had a date on Saturday nights.

I didn’t get my complacent butt out of there until he raised his hand to smack me during a disagreement. Though his hand never connected, that near-slap was just the push I needed.

Any sign of abuse (physical or emotional) is an obvious relationship deal-breaker. And the same goes for addictions of any stripe (drugs, alcohol, sex, gambling). But even without such problems, we often find ourselves spinning our wheels in dead-end relationships. Why do smart women make such foolish choices?

According to relationship experts, here are the 6 most common reasons we stay with men we’re just not that into:

1. My family made me do it.

“What happens in the family shapes how we see ourselves in the world, our core beliefs and our behaviors,” says life/relationship coach Lauren Mackler, author of Solemate: Master the Art of Aloneness and Transform Your Life (Hay House). “Then we take those behavior patterns into adulthood.”

So a girl who grew up thinking I don’t deserve love is subconsciously attracted to men who can’t meet her emotional needs.

“It doesn’t make her happy, but it’s comfortable because it’s familiar,” Mackler says.

It’s the emotional equivalent of the hamster wheel: You never get the guy, no matter how hard you work. But the thought that you might if you just hang on a little longer keeps you in the game.

“Women are willing to deal with long stretches of crap for that momentary approval or affection,” explains clinical psychologist Dennis P. Sugrue, Ph.D., co-author of Sex Matters for Women (Guilford Press). “When it comes – and it’s not often – the attention is almost like oxygen. It means everything.”

2. I won’t find anyone better.
So he’s boorish and overly critical. Breaks dates. Doesn’t call. Plays head games. Forgets your birthday. But he’s all yours. Would it be any different with anyone else?

Hello?!? Someone’s self-esteem needs a transfusion.

Blame this one, too, on a dysfunctional family dynamic.

When a woman is in a relationship with a clear loser, there’s a symbolic agenda playing out. It’s “usually not getting the love and affection of a parent,” Sugrue says. “So when things don’t go well, it becomes easier for her to rationalize it and take the blame for it.”

This pattern is one of the most destructive ways women sabotage themselves in work and relationships, says clinical psychotherapist Pat Pearson, author of Stop Self-Sabotage: Get Out of Your Own Way to Earn More Money, Improve Your Relationships and Find the Success You Deserve (McGraw Hill). We think, Well, it’s better than nothing.

“If we don’t believe we deserve to have a good relationship, we settle for less than what we could have or truly want,” she says. “We compromise our own integrity.”

3. I don’t want to be alone.

Then there’s the fear that you’ll end up a lonely spinster, so you hang on longer than you should out of a misguided sense of self-preservation.

Chalk this one up to family issues again, especially if the message you internalized growing up was, “You need a man to take care of you.”

“Fear of being alone is a huge factor that keeps people in bad relationships,” says Mackler, the life/relationship coach. “The underlying message is that you’re not able to take care of yourself.”

So you get into relationships with Mr. Wrong.

4. He’ll change.

Uh-huh. Tell it to the Tooth Fairy. Women have been deluding themselves with this particular fairy tale since cave gals sat around the fire pit, grousing that their men were such Neanderthals.

Don’t bet the farm on him changing in any substantial way. Improving hair and wardrobe is about the best you can do. (Though you might make some headway with the toilet-seat-down thing.) But serious character flaws? Figure on living with ’em… or leaving him.

“What you see is what you’re going to get,” Sugrue says. “If there is change, consider that to be a gift from heaven. But don’t count on it.”

5. He needs me.

If ever there was a big enough ball to keep you chained to a loser, it’s this one. We love being needed. We eat that up like a chocolate chip hot fudge sundae with a cherry on top.

“Women tend to over-give to people who don’t give as much back,” says Pearson, the clinical psychologist. “We’ve all been taught that we shouldn’t be selfish and to keep on giving even if we don’t get it back.”

We tell ourselves we’re indispensable. Or maybe you do have legitimate worries that if you split, he’d gamble, drink, slide into depression or kill himself.

But what you call “love,” therapists label as “co-dependency,” “enabling” or “emotional extortion.”

We’re then sucked into unhealthy relationships because serving in their lives makes us feel good about ourselves, explains Michele Sugg, a certified sex therapist in Branford, Conn. “It can be tough to move past the guilt and believe that he’ll make it, that you’re not his only lifeline.”

6. The sex is phenomenal.

That hormonal surge of oxytocin that courses through your brain when you have mind-blowing sex is designed to bond you to your partner. It’s emotional super-glue. But this neurochemistry can backfire when we bond with the wrong guy.

“Just because it was the best sex you ever had doesn’t mean that this is the best partner for you,” says certified sex therapist and psychologist Stephanie Buehler, Psy.D, of the Buehler Institute for sex therapy in Irvine, Calif.

And if you feel embarrassment or shame about becoming sexual too quickly, you might be tempted “to make a relationship out of the encounter,” Buehler says.

Should You Stay or Go?

These steps can get you thinking – honestly – about the state of your union.

1.Search your soul.

Ask yourself these questions, Sugrue says:

Do I really care about this person or has the relationship become habit?
Is it easier to stay than make the effort to leave?
Do I feel like he really cares for me? Or am I doing all the heavy lifting?
Would I be tempted to leave If someone else I’m attracted to was suddenly available and I could get out of my current relationship with no negative consequences, embarrassment, shame or explanations? If you’re thinking maybe, “that should tell you something,” Sugrue says.

2. Make a list. Works with Christmas gifts and relationships.Figure out what works (and doesn’t) in your relationship, Sugg says. “That can help you determine what needs to change for the relationship to feel healthier for you.”

So make like Santa and check your list twice. And talk it over with your guy. Maybe he didn’t realize that openly flirting with other women gets on your nerves. It’s unlikely, but at least you’ve done due diligence before you walk out.

3. Get online.

If you just don’t think you can do any better, click through some online dating sites. You don’t even need to post a profile. Just punch in your zip code and take a look at who’s around. Nice guys! Near you!

It’s the relationship equivalent of window-shopping. Not all these dudes will pony up to ride into the sunset with you. But even if you’re convinced the sea is empty, you’ll see there are plenty of fish out there.

4. Take a break.

Absence can make the heart grow fonder… or show you that you’re doing just fine without him. Either way, you get some perspective, Buehler says.

5. Hold off on hooking up.

No judgment here. Casual, no-strings-attached sex definitely has its place. However, “it’s important to look at what you’re trying to get when you’re hooking up,” Sugg says.

If you want to meet your dream man and live happily ever after, hooking up is “not the way you’re going to form lasting relationships,” Sugg says.

6. Do a reality check.

If you worry that ditching an unsatisfying relationship will leave you alone forever or possibly even destitute, take a deep breath and step back from the ledge.

Therapists call this “awfulizing” or “catastrophizing.” Mackler says you’re playing the Gloom and Doom Movie by imagining the absolute worst-case scenario, and it’s spinning in your mind as reality. So take stock

“Look at the core beliefs you have about yourself that’s driving this fear,” she says.

Do you really believe you’ll die without someone to take care of you? What about those friends and family who love you? And don’t you have your own money to pay those bills?

Looks like an apartment with only cats for company isn’t your destiny after all. And you’re doing pretty well fending for yourself. Soon you’ll get your brain around the idea that you can jump ship if you want to – and land on your feet.

Then you can start thinking about what your new movie will look like, Mackler says. Perhaps the screen will show that you can be happy without a relationship. Or that the next guy you date will appreciate and respect you.

Roll tape…

Are You Just Not That Into Him?

Many people stay in relationships because they are convenient or comfortable. Take this quiz and find out whether you’re into him or not.

Check out Health Bistro, where Lifescript editors let it all hang out. Share it with your friends (it’s free to sign up!), and bookmark it so you don’t miss a single juicy post!

Blaming your issues on Mom, Dad, your siblings or the dog can get a little tired. But persistently picking Mr. Wrong does have a lot to do with your upbringing, therapists say.

dealing with verbal abuse

faithful — Thu, 01 Oct 2009 13:17:27 +0000

Dealing With Verbal Abuse

By Lacey Michaels

Published May 22, 2007

Verbal abuse is a type of abuse that goes unrecognized in most cases because it is a subtle, invisible sort of abuse that leaves scars on the inside. Anyone can be a victim of verbal abuse, no matter what their age, color, or gender and anyone can become a verbal abuser as well. When we think of abuse, we tend to think of the man who slaps his wife around and leaves her with black eyes or the women at a shelter hiding from her murderous husband. We might even be grateful that we are with a man who does not hit us. But does he hit you with his words instead of his fists?

“Sticks and Stones can Break my Bones”

But words still can and do hurt you. You may never go to the hospital with your scars from verbal abuse, but the pain you are feeling is real and the damage that is done to you is real as well. Abusive words come in many forms, one of which is constant and malicious name calling. If you are called terrible things on a daily basis, a part of you will be beaten down by hearing them and you may even begin to internalize the sentiments. You might also realize that you are becoming more timid and less assertive or otherwise altering your behavior to try to get the abuser to stop.

You are a victim ofyour husband’s verbal abuse and that is how you are responding, trying to protect your self-esteem.

No one Listens to me

Another terrible fact of verbal abuse is that it often goes unrecognized. You might tell someone in order to seek help and instead of hearing the encouragement that you need, you hear that you are wrong. You might hear that you should be grateful that he is only calling you names, or thankful that he is a good provider. You might also hear that you should not place your hurt feelings above the integrity of your relationship. It is important to realize that this is about so much more than having your feelings hurt. Verbal abuse causes lasting psychological damage and is just as dangerous to you as physical abuse is, even if the danger is different.

Women who suffer from constant verbal abuse might find that they are incapable of dealing with critique or criticism from others anymore. They might quit their jobs to avoid the strain and find that they are living at the mercy of their abusive spouse with no means to escape the cycle of abuse. If you confide in someone and they tell you that you are just imagining things or that you are being too sensitive, find someone who knows how to help.

I’m Scared of Him

Verbal abuse does not just come in the form of name calling, although that is a big part of it.

In addition to being told that you are worthless or that you are pathetic (both of which you are not), you might hear him threaten you or your loved ones. The threat of violence is a crime just as the actual act of violence is and this mental terrorism is wrong and cruel. No one deserves to be threatened with physical harm or death. In addition to those threats, he might threaten to do something like kill himself or leave you alone, both of which are still verbal abuse and attempts to control you. He might also threaten to do harm to your children, your friends, or members of your family if you ever leave him or if you break another of his commandments. This behavior is dangerous and should be reported to the police. Take your children with you and make your escape. Call your friends and family to warn them if you are afraid for them and escape from the abusive situation before it is too late.

He doesn’t Mean it

Many men become abusive when they drink or are otherwise under the influence. If this is the case with your partner, you may think that if you can only get him sober, everything will be okay. You will also likely forgive his transgressions because he is sorry later and apologizes to you. This roller coaster of emotions that he is putting you on can be dangerous to your health and to your emotional well being.

If he cannot see how much harm this behavior is doing to you and to your psyche, then it is time for you to escape from the situation. Whether he means it or not, the fact remains that he does it and that is the fact that you have to get away from before the verbal abuse potentially turns into something more severe.

I Stay for the Children

If you have children with your abuser and this is the reason you are staying, then you are setting them up for a lifetime of abuse. Your children will learn that men call women names and make threats and that the women submit and allow the man to make threats. Your daughters may even seek out men like their father who will abuse them when they are older.

Just because your husband or partner does not actually abuse the children does not mean that even the youngest are unaware of what is going on around them. Children are not stupid, in fact they are incredibly astute by nature and they will see that you are suffering and that you allow yourself to be put in a situation where you will continue to suffer. Do whatever you have to in order to get your children away from your dangerous spouse and into a safe place environment.

Time to Move On

Once you have decided to leave your dangerous partner, make the transition quickly and immediately.

You do not want to let him know that you are going to leave him or he will have the opportunity to take his frustration and anger out on you, your children, or your family and friends. Your safety relies on being able to escape from him quickly and get to somewhere safe. Call your parents for their help and protection and call the police if you fear that he will find you or come after you.

Leaving your verbally abusive spouse does present a certain amount of danger, however, that danger is one that will pass as you heal. The danger of verbal abuse will only drag on and on if you stay with him and will end badly with him escalating to physical abuse or with you taking your own life in desperation to escape. Do not let your abuser win. Escape now while you have your chance and allow yourself to heal. Verbal abuse is not a lesser kind of abuse, it is just harder to recognize.

Are You in an Abusive Relationship?

How bad does it have to get before you say enough is enough? An abusive relationship saps your energy, strips away your dignity and can be physically dangerous to you and your family. If you’re not sure whether or not your relationship is abusive, answer the following questions honestly in this abusive relationship quiz.

back pain, sciatica and treatment

faithful — Thu, 20 Aug 2009 20:46:11 +0000

Back pain and sciatica

Highlights

Statistics:

According to the Bureau of Labor Statistics, in 2006 back pain was responsible for 62% of cases of people missing work due to pain involving the upper body.

Overview:

Back pain can be acute, subacute, or chronic.
- Acute back pain develops suddenly and lasts up to several weeks. Acute pain is the most common type of back pain.
- Subacute back pain is pain that lasts up to three months.
- Chronic back pain can begin abruptly or gradually, but it lasts longer than 3 months.
Back pain can occur in any area of the back, but it is more common in the lower part, which supports most of the body’s weight.

Diagnosis:

Although most episodes of new back pain, as well as flare-ups of chronic back pain, clear up or return to a previous level of discomfort, a medical history and a brief physical examination is always necessary.
The main goal of a physical exam is to try and determine the source of the pain and the limits of movement.
Because most patients with back pain are on the mend or completely recovered within 6 weeks, imaging techniques such as x-rays or scans are rarely recommended in the first month unless the health care provider suspects a tumor, fracture, infection, cauda equina syndrome, or progressive neurological disease.

Treatment:

The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs)
Injections of corticosteroids (commonly called steroids) are sometimes used to treat low back pain caused by nerve impingement.
Spinal manipulation may sometimes be useful for acute back pain that persists beyond 2 – 3 weeks.
Patients should always try all possible non-surgical treatments before opting for surgery.

Introduction

Back pain is one of the most common reasons people visit their doctor. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 8 out of 10 people have some type of backache.

Back pain can be acute, subacute, or chronic.

Acute back pain develops suddenly and lasts up to several weeks. Acute pain is the most common type of back pain.
Subacute back pain is pain that lasts up to 3 months.
Chronic back pain can begin abruptly or gradually, but it lasts longer than 3 months.

Back pain can occur in any area of the back, but it is more common in the lower back, which supports most of the body’s weight.

The Spine

The back is highly complex, and pain may result from damage or injury to any of its various bones, nerves, muscles, ligaments, and other structures. Still, despite sophisticated techniques, which provide detailed anatomical images of the spine and other tissues, the cause of most cases of back pain remains unknown.

Vertebrae. The spine is a column of small bones, or vertebrae, that support the entire upper body. The column is grouped into three sections:

The cervical (C) vertebrae are the seven spinal bones that support the neck.
The thoracic (T) vertebrae are the twelve spinal bones that connect to the rib cage.
The lumbar (L) vertebrae are the five lowest and largest bones of the spinal column. Most of the body’s weight and stress falls on the lumbar vertebrae.

Click the icon to see an image of the spine.

Below the lumbar region is the sacrum, a shield-shaped bony structure that connects with the pelvis at the sacroiliac joints.

At the end of the sacrum are two to four tiny, partially fused vertebrae known as the coccyx, or “tail bone.”

Click the icon to see an image of the sacrum.

Each vertebra is designated by using a letter and number, allowing the doctor to determine where it is in the spine.

The letter reflects the spinal region where the vertebra is located:
- C=cervical (neck region)
- T= thoracic (chest, or middle back, region)
- L=lumbar (lower back)
The number signifies the vertebra’s place within that spinal region. The numbers start with 1 at the top of a region and count up as the vertebrae descend within the region. For example, C4 is the fourth bone down in the cervical region, and T8 is the eighth thoracic vertebrae.

The Disks. Vertebrae in the spinal column are separated from each other by small cushions of cartilage known as intervertebral disks. The disks have no blood supply of their own. They rely on nearby blood vessels to keep them nourished.

Click the icon to see an image of an intervertebral disk.

Each disk is 80% water and contains two structures.

Inside each disk is a jelly-like substance called the nucleus pulposus.
The nucleus pulposus is surrounded by a tough, fibrous ring called the annulus.

Click the icon to see an image of the nucleus pulposus.

Processes. Each vertebra in the spine has a number of bony projections called processes. The spinous and transverse processes attach to the muscles in the back and act like little levers, allowing the spine to twist or bend. The particular processes form the joints between the vertebrae themselves, meeting together and interlocking at the zygapophysial joints (more commonly known as facet, or z-joints).

Spinal Canal. Each vertebra and its processes surround and protect an arch-shaped central opening. These arches, aligned to run down the spine, form the spinal canal, which encloses the spinal cord.

Click the icon to see an image of the vertebrae and spinal cord.

Spinal Cord. The spinal cord is the central trunk of nerves that connects the brain with the rest of the body. Each nerve root passes from the spinal column to other parts of the body through small openings, bounded on one side by the disk and on the other by the facets. When the spinal cord reaches the lumbar region, it splits into four bundled strands of nerve roots called the cauda equina (meaning horsetail in Latin).

Click the icon to see an image of the cauda equina.

Symptoms and Causes

The origin of the pain is often unknown, and imaging studies may fail to determine its cause. Disk disease, spinal arthritis, and muscle spasms are the most common diagnoses. Other problems can also cause back pain, however.

Muscle and Ligament Injuries/Lumbar Strain

Strain and injury to the muscles and ligaments supporting the back are the major causes of low back pain. The pain is typically more spread out in the muscles next to the spine, and may be associated with spasms in those muscles. The pain may move to the buttocks but rarely any farther down the leg.

Sciatica

The sciatic nerve is a large nerve that starts in the lower back.

It forms near the spine and is made up from branches of the roots of the lumbar spinal nerves.
It travels through the pelvis and then deep into each buttock.
It then travels down each leg. It is the longest and widest single nerve in the body.

Sciatica is not a diagnosis but a description of symptoms. Anything that places pressure on one or more of the lumbar nerve roots can cause pain in parts or all of the sciatic nerve. A herniated disk, spinal stenosis, degenerative disc disease, spondylolisthesis, or other abnormalities of vertebrae can all cause pressure on the sciatic nerve.

Some cases of sciatica pain may occur when a muscle located deep in the buttocks pinches the sciatic nerve. This muscle is called the piriformis. The resulting condition is called piriformis syndrome. Piriformis syndrome usually develops after an injury. It is sometimes difficult to diagnose.

The main nerve traveling down the leg is the sciatic nerve. Pain associated with the sciatic nerve usually originates when nerve roots in the spinal cord become compressed or damaged. Symptoms can include tingling, numbness, or pain that radiates to the buttocks, legs, and feet.

Pain or numbness due to sciatica can vary widely. It may feel like a mild tingling, dull ache, or a burning sensation. In some cases, the pain is severe enough to cause immobility.

The pain most often occurs on one side and may radiate to the buttocks, legs, and feet. Some people have sharp pain in one part of the leg or hip and numbness in other parts. The affected leg may feel weak.

The pain often starts slowly. Sciatica pain may get worse:

At night
After standing or sitting for long periods of time
When sneezing, coughing, or laughing
After bending backwards or walking more than 50 – 100 yards (particularly if it is caused by spinal stenosis — see below)

Sciatica pain usually goes away within 6 weeks, unless there are serious underlying conditions. Pain that lasts longer than 30 days, or gets worse with sitting, coughing, sneezing, or straining may indicated a longer recovery. Depending on the cause of the sciatica, symptoms may come and go.

Herniated Disk

A herniated disk, sometimes (incorrectly) called a slipped disk, is a common cause of severe back pain and sciatica. A disk in the lumbar area becomes herniated when it ruptures or thins out, and degenerates to the point that the gel within the disk (the nucleus pulposus) pushes outward. The damaged disk can take on many forms:

A bulge — The gel has been pushed out slightly from the disk and is evenly distributed around the circumference.
Protrusion — The gel has pushed out slightly and asymmetrically in different places.
Extrusion — The gel balloons extensively into the area outside the vertebrae or breaks off from the disk.

Pain in the leg may be worse than the back pain in cases of herniated disks. There is also some debate about how pain develops from a herniated disk and how frequently it causes low back pain. Many people have disks that bulge or protrude and do not suffer back pain. Extrusion (which is less common than the other two conditions) is highly associated with back pain, since the gel is likely to extend out far enough to press against the nerve root, most often the sciatic nerve. Extrusion is very uncommon, however, while sciatic and low-back pain are very common. But there may be other causes of low back pain.

Abnormalities in the Annular Ring. Research has also focused on tears in the annular ring — the fibrous band that surrounds and protects the disk. The annular ring contains a dense nerve network and high levels of peptides that heighten perception of pain. Tears in the annular ring are a frequent finding in patients with degenerative disk disease. Some cases of chronic low back pain may be caused by inward growth of nerve fibers into the annular ring, which triggers pain within the intervertebral disk.

Cauda equina syndrome. Cauda equina syndrome is the impingement of the cauda equina (the four strands of nerves leading through the lowest part of the spine). The cause is usually massive extrusion of the disk material. Cauda equina syndrome is an emergency condition that can cause severe complications to bowel or bladder function. It can cause permanent incontinence if not promptly treated with surgery. Symptoms of the cauda equina syndrome include:

Dull back pain
Weakness or numbness in the buttocks, in the area between the legs, or in the inner thigh, backs of legs, or feet; may cause stumbling or difficulty in standing
An inability to control urination and defecation
Pain accompanied by fever (can indicate an infection)

Lumbar Degenerative Disk Disease/Spondylosis

Osteoarthritis occurs in joints of the spine, usually as a result of aging, but also in response to previous back injuries, excessive wear and tear, previously herniated discs, prior surgeries, and fractures. Cartilage between the joints of the spine is destroyed and extra bone growth or bone spurs develop. The rate at which these changes develop varies between people.. The end result of these changes is a gradual loss of mobility of the spine, narrowing of the spaces for spinal nerves and spinal cord, and drying out or degeneration of the spinal discs. Depending on which part and how much of the spine is involved, symptoms may be similar to that of a herniated disc, lumbar strain, or spinal stenosis (narrowing of the spinal canal).

Spinal Stenosis

Spinal stenosis is the narrowing of the spinal canal, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This condition typically develops as a person ages and the disks become drier and start to shrink. At the same time, the bones and ligaments of the spine swell or grow larger due to arthritis and chronic inflammation. However, other problems, including infection and birth defects, can sometimes cause spinal stenosis.

Most patients will report the presence of gradually worsening history of back pain over time. For others, there may be minimal history of back pain, but at some point in this process any disruption, such as a minor injury that results in disk inflammation, can cause impingement on the nerve root and trigger pain.

Patients may experience pain or numbness, which can occur in both legs, or on just one side. Other symptoms include a feeling of weakness or heaviness in the buttocks or legs. Symptoms are usually present or will worsen only when the person is standing or walking upright. Often the symptoms will ease or disappear when sitting down or leaning forward. These positions may create more space in the spinal canal, thus relieving pressure on the spinal cord or the spinal nerves. Patients with spinal stenosis are not usually able to walk for long periods of time. They may be able to ride an exercise bike.

Spondylolisthesis

Spondylolisthesis occurs when one of the lumbar vertebrae slips over another, or over the sacrum.

In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum area. It is often due to a birth defect in that area of the spine. In adults, the most common cause is degenerative disease (such as arthritis). The slip usually occurs between the fourth and fifth lumbar vertebrae. It is more common in adults over 65 and women.

Other causes of spondylolisthesis include stress fractures (commonly seen in gymnasts) and traumatic fractures. Spondylolisthesis may occasionally be associated with bone diseases.

Spondylolisthesis may vary from mild to severe. It can produce increased lordosis (swayback), but in later stages may result in kyphosis (roundback) as the upper spine falls off the lower spine.

Symptoms may include:

Lower back pain
Pain in the thighs and buttocks
Stiffness
Muscle tightness
Tenderness in the slipped area

Pain generally occurs with activity and is better with rest. Neurological damage (leg weakness or changes in sensation) may result from pressure on nerve roots, and may cause pain radiating down the legs.

Inflammatory Conditions and Arthritis

Inflammatory disorders and arthritis syndromes can produce inflammation in the spine.

Ankylosing spondylitis is a chronic inflammation of the spine that may gradually result in a fusion of vertebrae. Symptoms include a slow development of back discomfort, with pain lasting for more than 3 months. The back is usually stiff in the morning; pain improves with movement or exercise. In severe cases, the patient stands or sits stooped over. It can be quite mild, however, and it rarely affects a person’s ability to work. It occurs mostly in young Caucasians in their mid-20s. The disease is more common in men, but about 30% of the cases are in women. Researchers believe that in most cases the cause is hereditary.

About 20% of people with inflammatory bowel disease and about 20% of people with psoriasis develop a similar form of arthritis involving the spine. There are multiple treatments for this potentially disabling disease, including various immune suppressant medications. Etanercept (Enbrel) and infliximab (Remicade), anti-inflammatory agents known as TNF-blockers, are proving to be beneficial.

Osteoporosis and Compression Fractures

Osteoporosis is a disease of the skeleton in which the amount of calcium present in the bones slowly decreases to the point where the bones become fragile and prone to fractures. It usually does not cause pain unless the vertebrae collapse suddenly, in which case the pain is often severe. More than one vertebra may be affected.

In a compression fracture of the vertebrae, the bone tissue of the vertebra collapses. More than one vertebra may collapse as a result. When the fracture is the result of osteoporosis, the vertebrae in the thoracic (chest) and lower spine are usually affected, and symptoms may be worse with walking.

With multiple fractures, kyphosis (a forward hump-like curvature of the spine) may result. In addition, compression fractures are often responsible for loss of height. Pressure on the spinal cord may also occur, producing symptoms of numbness, tingling, or weakness. Symptoms depend upon the area of the back that is affected; however, most fractures are stable and do not produce neurological symptoms. [For more information, see In-Depth Report #18: Osteoporosis.]

Back Pain Emergencies

Several serious conditions can also cause back pain. Often, these symptoms develop over a short period of time, become more severe, and may have other findings that go along with them. Some of these conditions include:

Infection in the bone (osteomyelitis) or the disk (diskitis)
Cancer that has spread to the spine from another part of the body (most commonly lung cancer, colon cancer, prostate cancer, and breast cancer)
Cancer that begins in the bones (the most common diagnosis in adults is probably multiple myeloma, seen in middle age or older adults); benign tumors such as osteoblastoma or neurofibroma and cancers, including leukemia, can also cause back pain in children
Trauma

Miscellaneous Abnormalities and Diagnoses

Any abnormality in joints, vertebrae, or nerve roots can cause back pain, including:

Fibromyalgia.
Other medical conditions that cause referred back pain, occurring in conjunction with problems in organs unrelated to the spine (although usually located near it); such conditions include ulcers, kidney disease (including kidney stones), ovarian cysts, and pancreatitis.
Chronic uterine or pelvic infections can cause low back pain in women.
The facet joints (z-joints) can wear down; in such cases, pain occurs on arching the back or when walking.
In some cases a segment (consisting of two vertebrae and their common joint and disk) becomes unstable when its parts wear down.
Injury to nerve roots, notably deep root ganglia (nerve cells in the spine whose fibers extend from skin to muscle tissue), may be important in some cases; some patients may have scar tissue that traps the nerve roots in the lower spine and causes sciatica.

Risk Factors

In most known cases, pain begins with an injury, after lifting a heavy object, or after making a sudden movement. Not all people have back pain after such injuries, however. In the majority of back pain cases, the causes are unknown.

Aging

Intervertebral disks begin deteriorating and growing thinner by age 30. One-third of adults over 20 show signs of herniated disks (although only 3% of these disks cause symptoms). As people continue to age and the disks lose moisture and shrink, the risk for spinal stenosis increases. The incidence of low back pain and sciatica increases in women at the time of menopause as they lose bone density. In older adults, osteoporosis and osteoarthritis are also common. However, the risk for low back pain does not mount steadily with increasing age, which suggests that at a certain point, the conditions causing low back pain plateau.

High-Risk Occupations

Jobs that involve lifting, bending, and twisting into awkward positions, as well as those that cause whole-body vibration (such as long-distance truck driving), place workers at particular risk for low back pain. The longer a person continues such work, the higher their risk. Some workers wear back support belts, but evidence strongly suggests that they are useful only for people who currently have low back pain. The belts offer little added support for the back and do not prevent back injuries.

A number of companies are developing programs to protect against back injuries. However, studies have been mixed on the outcome of company interventions. Employers and workers should make every effort to create a safe working environment. Office workers should have chairs, desks, and equipment that support the back or help maintain good posture.

Low back pain accounts for significant losses in workdays and dollars. According to the Bureau of Labor Statistics, back pain was responsible for around 60% of cases of people missing work due to pain involving the upper body. A 2004 study analyzed health care expenses in the United States. The analysis found back pain cost over $90 billion, of which $26 billion was spent directly on treating the back pain.

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

Medical Conditions in Children

Persistent low back pain in children is more likely to have a serious cause that requires treatment than back pain in adults.

Stress fractures (spondylolysis) in the spine are a common cause of back pain in young athletes. Sometimes a fracture may not show up for a week or two after an injury. Spondylolysis can cause spondylolisthesis, a condition in which the spine becomes unstable and the vertebrae slip over each other.

Hyperlordosis is an inborn exaggerated inward curve in the lumbar area. Scoliosis, an abnormal curvature of the spine in children, does not usually cause back pain.

Juvenile chronic arthropathy is an inherited form of arthritis. It can cause pain in the sacrum and hip joints of children and young people. It used to be grouped under juvenile rheumatoid arthritis, but is now defined as a separate problem.

Injuries can also cause back pain in children.

Pregnancy

Pregnant women are prone to back pain due to a shifting of abdominal organs, the forward redistribution of body weight, and the loosening of ligaments in the pelvic area as the body prepares for delivery. Tall women are at higher risk than short women.

Psychological and Social Factors

Psychological factors are known to play a strong influential role in three phases of low back pain:

Some evidence suggests preexisting depression and the inability to cope may be more likely to predict the onset of pain than physical problems. A “passive” coping style (not wanting to confront problems) was strongly associated with the risk of developing disabling neck or low back pain.
Social and psychological factors, as well as job satisfaction, all play a role in the severity of a person’s perception of back pain. For example, one study compared truck drivers and bus drivers. Nearly all the truck drivers liked their work. Half of them reported low back pain but only 24% lost time at work. Bus drivers, on the other hand, reported much lower job satisfaction than truck drivers, and these workers with back pain had a significantly higher absentee rate than truck drivers in spite of less stress on their backs. Similarly, another study found that pilots, who generally reported “loving their jobs,” reported far fewer back problems than their flight crews. And yet another study reported that low rank, low social support, and high stress in soldiers was associated with a higher risk for disabling back pain.
Depression and a tendency to develop physical complaints in response to stress also increase the likelihood that acute back pain will become a chronic condition. The way a patient perceives and copes with pain at the beginning of an acute attack may actually condition the patient to either recover or develop a chronic condition. Those who over-respond to pain and fear for their long-term outlook tend to feel out of control and become discouraged, increasing their risk for long-term problems.

Studies also suggest that patients who reported prolonged emotional distress have less favorable outcomes after back surgeries. It should be strongly noted that the presence of psychological factors in no way diminishes the reality of the pain and its disabling effects. Recognizing this presence as a strong player in many cases of low back pain, however, can help determine the full range of treatment options.

Diagnosis

Although most episodes of new back pain, as well as exacerbations of chronic back pain, clear up or return to a previous level of discomfort, a medical history and a brief physical examination is always necessary. Depending on the severity of the symptoms, how long they have been present, and any associated medical problems, history and physical exam alone may or may not be sufficient.

Medical History

The patient should be able to describe the back pain and its history in the following manner:

Frequency, duration, and nature of the pain
When the pain occurs
What triggered the pain (such as lifting a heavy object)
Conditions that make the pain worse, such as coughing
Other relevant symptoms, such as morning stiffness, weakness, or numbness in the legs
Previous episodes of back pain
Severity of the pain and how it affects the person’s ability to perform everyday activities or work activities
Any situation that relieves the pain
Any history of injuries or accidents involving the neck, back, or hips
Other medical conditions, such as arthritis or osteoporosis

A patient should report any serious health problems, symptoms, and concerns that may raise a red flag for a more serious condition. These include:

HIV infection or AIDS
Pain that is persistently increasing in intensity and cannot be relieved
Fever that is associated with the back pain
Any new or worsening neurological symptoms, such as weakness in a specific part of the legs or feet
History of cancer, or currently being treated for cancer
Problems emptying the bowels or bladder, including incontinence
Unexplained weight loss

Physical Examination

The main goal of a physical exam is to try and determine the source of the pain and the limits of movement.

Patients are asked to sit, stand, and walk in different ways (flat-footed, on the toes, and on their heels).
Patients will be requested to bend forward, backward, and sideways and to twist.
Patients will be asked to lift their leg straight up while lying down. The health care provider will also move the patient’s legs in different positions and bend and straighten the knees. (Pain caused by sciatica can be intensified by lifting the affected leg straight in the air. It is usually sharp, localized, and accompanied by numbness or tingling. Pain caused by inflammation is duller and more generalized and not affected by lifting a straight leg.)
The health care provider may measure the circumference of the calves and thighs to look for muscle wasting.
To test nerve function and reflexes, the health care provider will tap the knees and ankles with a rubber hammer. The health care provider may also touch parts of the body lightly with a pin, cotton swab, or feather to test for numbness and nerve sensitivity.
The health care provider will assess strength in different muscle groups of the legs.

Imaging Techniques

Imaging tests used to evaluate back pain range from a simple x-ray to a CT scan or MRI of the spine. Depending on medical diagnoses that are identified by the history, the patient may need such tests as a Dual energy X-ray absorptiometry (DEXA) scan for osteoporosis or a nuclear scan for suspected arthritis, cancer, or infection.

Because most patients with back pain are on the mend or completely recovered within 6 weeks, imaging techniques such as x-rays or scans are rarely recommended in the first month unless the health care provider suspects a tumor, fracture, infection, cauda equina syndrome, or progressive neurological disease.

Even when symptoms last longer, unless a potentially serious diagnosis is suspected, MRI or CT scans can often be delayed until the time when surgery or epidural steroid injections come into consideration as treatment options.

X-Rays. Many patients with acute and uncomplicated low back pain believe that plain x-rays of the spinal column are important in a diagnosis. However, they are not very helpful in most patients with nonspecific back pain.

Patients who have the following symptoms or experience certain events may need more sophisticated imaging studies:

Significant pain that lasts more than 1 – 2 months
Symptoms such as pain, numbness, or tingling extending from the buttocks down the leg that are very severe or get worse
Muscle weakness that is significant, persistent, or getting worse
A previous accident or injury that might have affected the disks or vertebra
A history of cancer
Indications of an underlying disease such as fever or unexplained weight loss
New pain that occurs in patients over 65 years of age

Magnetic Resonance Imaging (MRI). Magnetic resonance imaging (MRI) can provide very well-defined images of soft tissue and bone. The test is not painful or dangerous, but some people may feel claustrophobic in scanners where they are fully enclosed. MRIs can detect tears in the disks, disk herniation, or disk fragments. It can also detect spinal stenosis. and non-spinal causes of back pain, including infection and cancer.

MRI scans often detect spine abnormalities that are not causing symptoms in the patient. At least 40% of all adults have bulging or protruding vertebral disks, and most have no back pain. Also, the degree of disk abnormalities revealed by MRIs often has very little to do with the severity of the pain or the need for surgery. Disk abnormalities in people who have back pain may simply be a coincidence rather than an indication for treatment.

Patients are also more likely to think of themselves as having a serious back problem if abnormalities are identified on MRI scans, even if the scans do not result in treatment changes. This perception may sometimes slow down their recovery.

Click the icon to see an image of a MRI machine.

CT stands for computerized tomography. In this procedure, a thin x-ray beam is rotated around the area of the body to be visualized. Using very complicated mathematical processes called algorithms the computer is able to generate a 3-D image of a section through the body. CT scans are very detailed and provide excellent information for the doctor.

Bone Scintigraphy and SPECT Imaging. In rare cases, doctors may use bone scintigraphy (bone scanning) to determine abnormalities in the bones. The technique may be useful for early detection of spinal fractures, cancer that has spread to the bone, or certain inflammatory arthritic conditions. During this exam, a small amount of radioactive material is injected into a vein. It circulates through the body, and is absorbed by the bones. The bones can then be seen using x-rays or single photon emission computed tomography (SPECT).

An x-ray myelogram is an x-ray of the spine that requires a spinal injection of a special dye and the need to lie still for several hours to avoid a very painful headache. It has value only for select patients with pain on moving and standing. It has largely been replaced by CT and MRI scans.

Electrodiagnostic Tests

Tests that analyze the electric waveforms of nerves and muscles may be useful for detecting nerve abnormalities that may be causing back pain, and identifying possible injuries. They are also useful to determine if any abnormal structural findings on an MRI or other imaging tests have real significance as a cause of back pain. It should be noted that any nerve injuries that affect these tests may not be present for 2 – 4 weeks after symptoms begin.

Nerve conduction studies and electromyography are the electrodiagnostic tests most commonly performed. These tests are not used often in the evaluation and management of patients with low back pain.

Other Tests

Diskography: Since many people have evidence of disk degeneration on their MRI scans, it is not always easy to tell if the finding on this MRI scan explains pain the patient may be experiencing. Diskography is a test that is used to help determine whether an abnormal disk seen on MRI explains someone’s pain. When performed, it is generally reserved for patients who did not experience relief from other therapies, including surgery. This procedure requires injections into disks suspected of being the source of pain and disks nearby. It can be painful. There is controversy among physicians who take care of the spine regarding the usefulness of diskography for making decisions about care, particularly surgery

Blood and urine samples may be used to test for infections, arthritis, or other conditions.

Injecting a drug that blocks pain into the nerves in the back helps locate the level in the spine where problems occur.

A procedure called a facet block is also useful in locating areas of specific damage.

Medications

Patients should understand that most people who have sudden low back pain, even with sciatica, have a high likelihood of substantial improvement over the first month.

The most commonly prescribed medications for the treatment of back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). Evidence suggests that short-term use of NSAIDs brings effective relief in patients with acute back pain. The benefits of NSAIDs for chronic back pain are less certain.

There are dozens of available NSAIDs:

Over-the-counter (OTC) NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT).
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), and dexibuprofen (Seractil).
Taking NSAIDs with food can reduce stomach discomfort, although it may slow down the pain-relieving effect.

In April 2005, the Food and Drug Administration (FDA) asked drug manufacturers of prescription NSAIDs to include with their products the same warning label used for the COX-2 inhibitor celecoxib (Celebrex). This “black box” warning, the FDA’s strongest, emphasizes the increased risks for cardiovascular events (heart-related problems) and gastrointestinal (digestive tract) bleeding associated with the use of these drugs. The FDA also requested manufacturers of OTC NSAIDs to be more specific in their labels concerning potential cardiovascular and gastrointestinal risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions. In December 2006, the FDA proposed even stronger labeling changes to highlight the potential of these drugs to cause liver damage, as well as risks of alcohol and drug interactions with NSAIDs.

Long-term, regular use of NSAIDs can increase the risk for heart attack, especially for people who have a heart condition. Long-term use of NSAIDs is also the second most common cause of ulcers and gastrointestinal bleeding. To reduce the risks associated with NSAIDs, take the lowest dose possible for pain relief.

Other possible side effects of NSAIDs may include:

Upset stomach
Dyspepsia (burning, bloated feeling in pit of stomach)
Drowsiness
Skin bruising
High blood pressure
Fluid retention
Headache
Rash
Reduced kidney function

NSAID-Induced Ulcers and Gastrointestinal Bleeding

Long-term use of NSAIDs is the second most common cause of ulcers. Ulcers caused by NSAIDs are more likely to bleed than those caused by the bacteria Helicobacter pylori.

Those at high risk for bleeding include people over age 60, anyone with a history of ulcers or gastrointestinal bleeding, patients with serious heart conditions, people who abuse alcohol, and those who take medications such as anticoagulants (blood thinners) and corticosteroids.

Proton-pump inhibitor (PPI) drugs may help prevent and heal ulcers caused by NSAIDs. PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid).

COX-2 Inhibitors (Coxibs). Coxibs inhibit an inflammation-promoting enzyme called COX-2. This drug class was initially thought to provide benefits equal to NSAIDs but cause less gastrointestinal distress. However, following numerous reports of heart problems, skin rashes, and other adverse effects, the FDA re-evaluated the risks and benefits of this drug class. This lead to the removal of rofecoxib (Vioxx) and valdecoxib (Bextra) from the United States market. Celecoxib (Celebrex) is still available, but patients should ask their doctor whether the drug is appropriate and safe for them. In December 2006, the FDA approved celecoxib for the relief of symptoms of juvenile rheumatoid arthritis in patients ages 2 years and older.

An ulcer is a crater-like lesion on the skin or mucous membrane that is caused by an inflammatory, infectious, or cancerous condition. To avoid irritating an ulcer, stop smoking and try to eliminate certain substances from your diet, including caffeine and alcohol. Prescription medicines are available to suppress the acid in the stomach that causes erosion of the stomach lining. Endoscopic therapy can be used to stop ulcer-related bleeding.

Tramadol

Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. While the drug has opioid-like properties, it is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea, but does not cause the severe gastrointestinal problems that NSAIDs can. Some patients who take tramadol experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is now available. It provides more rapid pain relief than tramadol alone.

Opioid Pain Relievers

Narcotics are pain-relievers that act on the central nervous system. They are the most powerful medications available for the management of pain.

There are two types of narcotics:

Opiates, such as morphine and codeine, are derived from natural opium.
Opioids are synthetic drugs and include oxycodone (Percodan, Percocet, OxyContin), hydrocodone (Vicodin), and oxymorphone (Numorphan).

Opioids are effective for short-term relief of back pain. Using them for longer than 16 weeks to treat low back pain has not been well studied and may increase the risk of abuse, if a health care provider does not manage usage well.

Newer ways to deliver pain medicine have been developed. A skin patch containing an opioid called transdermal fentanyl (Duragesic) may relieve chronic back pain more effectively than oral opioids.

Common side effects of opioids include anxiety, constipation, nausea, vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing. Addiction is a risk, although less than is commonly believed when these medications are used for pain relief. In fact, when prescribed properly, use of opioids for chronic pain can be safer in some cases than on-going use of NSAIDs. Unfortunately, opioid abuse among young people is a major concern. Unless the pain is very severe, experts advise against routinely prescribing opioids.

Epidural Steroid Injections

Injections of corticosteroids (commonly called steroids) are sometimes used to treat low back pain caused by nerve impingement. The injection is placed into the epidural space, just inside the outer membrane covering the spine.

The injection is directed as close to the location of the affected nerve as possible. Corticosteroids reduce inflammation.

Studies that measure the benefits of steroid injections on sciatica or low back pain are conflicting.

No high quality studies have shown that these injections provide long-term benefit for most patients, compared to more conservative treatments. However, reasonable evidence shows that patients receive short-term pain relief, generally over a 1 – 2 month period, from these injections.

Serious and painful side effects, including meningitis and inflammation, are possible. However, such risks are very low.

Epidural steroid injections for spinal stenosis may provide short-term relief of pain but generally do not improve the patient’s daily functioning, nor do they help patients avoid surgery.

Botulinum Toxin Injections

Researchers are investigating whether injections of botulinum toxin (Botox) in the lower back can safely and effectively relieve pain. Botox is commonly used to smooth out wrinkles and to treat other neuromuscular disorders. Very small amounts of Botox temporarily paralyze muscle tissue. Some studies have suggested that Botox may be of help in relieving chronic low back pain but its role in the treatment of back pain has not yet been determined.

Antidepressants

Some studies show that antidepressants may lessen the severity of pain in some patients, although they have little effect on daily functioning. Antidepressants called tricyclics may be effective painkillers in non-depressed people with chronic back pain. Such antidepressants include amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), and maprotiline (Ludiomil).

Tricyclics can have severe side effects. Nonetheless, experts believe there is a useful role for these drugs that warrants further investigation.

A recent review of existing studies found no clear evidence that antidepressants help people with chronic low back pain. However, the reviewers noted that antidepressants help in other cases of chronic pain and that additional, larger studies are needed to clarify their effect on chronic low back pain.

Muscle Relaxants

A combination of nonsteroidal anti-inflammatory drugs and muscle relaxants — such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol (Soma), or methocarbamol (Robaxin) — are sometimes used for patients with acute low back pain. Evidence has shown that they can help relieve non-specific low back pain, but some experts warn that these drugs should be used cautiously, since they target the brain, not the muscles. Patients who take muscle relaxants may experience a number of central nervous system side effects, such as drowsiness. The muscle relaxant Soma can be addictive and does little more than induce sleep.

Herbs and Supplements

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body’s chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Most herbal remedies used for back pain are said to have both pain-relieving and anti-inflammatory effects. A few have been found to have some benefit when compared to placebo or sugar pill. However, none of these have been compared to other standard treatments.

White willow bark, bromelain, and Boswellia have blood-thinning properties and can interfere with anticoagulant medications, such as warfarin (Coumadin).

Other Treatments

A number of complementary and alternative treatments are used to relieve back pain. Complementary means it is used together with conventional medicine. Alternative means it is done in place of conventional medicine.

Acupuncture

Acupuncture is now a common alternative treatment for certain kinds of pain. It involves inserting small needles or exerting pressure on certain “energy” points in the body. When the pins have been placed successfully, the patient is supposed to experience a sensation that brings a feeling of fullness, numbness, tingling, and warmth with some soreness around the acupuncture point. Unfortunately, rigorous studies of acupuncture are difficult to perform, and most evidence on its benefits is weak. In any case, it may be specifically helpful for certain patients with back pain, such as pregnant women, who must avoid medications. Anyone who undergoes acupuncture should be sure it is performed in a reputable location by experienced practitioners who use sterilized equipment.

Acupuncture has not shown any benefits for acute low back pain in most patients, but may provide some help for patients with chronic low back pain.

Click the icon to see an image of acupuncture.

Massage Therapy

Some studies have shown that massage therapy can help some patients with chronic or acute back pain, especially when combined with exercise and patient education.

Cognitive-Behavioral Therapy

Some studies report that a course of cognitive-behavioral therapy helps reduce chronic back pain, or at least enhances the patient’s ability to deal with it. The primary goal of this form of therapy in such cases is to change the distorted perceptions that patients have of themselves, and change their approach to pain. Patients use specific tasks and self-observations to help them change their thinking. They gradually shift their perception of helplessness against the pain that dominates their lives into the perception that pain is only one negative among many positives and, to a degree, a manageable experience.

Spinal Manipulation

Chiropractors typically perform spinal manipulations, but so do osteopathic doctors.

One in three people with low back pain seeks treatment from a chiropractor. Chiropractic was founded in the U.S. in the late 1800s. The specific goal of chiropractors is to perform spinal manipulations to improve nerve transmission. Many studies have now confirmed that patients feel more satisfied with their chiropractic care than with treatment from general practitioners.
Osteopathy was also founded in the 1800s, and its core approach to healing also involves physical manipulation. Osteopathy manipulates the bones, muscles, and tendons to optimize blood circulation. The general direction of osteopathy over the years has widened to employ a broader range of treatments, which now approach those of standard medicine.

Spinal Manipulation for Uncomplicated Low Back Pain.

There is evidence of benefit for spinal manipulation treatment of subacute pain and exacerbations of chronic pain. Ongoing or maintenance spinal manipulation has not been proven to alter the course of chronic back pain.

Mild and temporary side effects from spinal manipulation are common. The potential for serious adverse effects from low back manipulations is low.

Some chiropractors may take a lot of x-rays, particularly those of the full spine, which may have long-term harmful consequences. Patients should also be aware that some chiropractors use alternative treatments that have not been proven or rigorously studied. All patients should require objective evidence on the benefits of their treatments.

Electrical Stimulation

Percutaneous Neuromodulation Therapy. A technique called percutaneous neuromodulation therapy (PNT) uses a small device that delivers electrical stimulation to deep tissues and nerve pathways near the spine.

Electrical Nerve Stimulation. Transcutaneous electrical nerve stimulation (TENS) uses low-level electrical pulses to suppress back pain. A variant of this procedure, percutaneous electrical nerve stimulation (PENS), applies these pulses through a small needle to acupuncture points.

When tested in high-quality studies, electrical nerve stimulation has not been found to provide much help.

Exercise and Physical Therapy

The Role of Physical Therapy

Physical therapy with a trained professional may be useful if pain has not improved after 3 – 4 weeks. It is important for any person who has chronic low back pain to have an exercise program. Professionals who understand the limitations and special needs of back pain, and can address individual health conditions, should guide this program. One study indicated that patients who planned their own exercise program did worse than those in physical therapy or doctor-directed programs.

Physical therapy typically includes the following:

Education and training the patient in correct movement.
Exercises to help the patient keep the spine in neutral positions during all daily activities.

Incorrect movements or long-term high-impact exercise is often a cause of back pain in the first place. People vulnerable to back pain should avoid activities that put undue stress on the lower back or require sudden twisting movements, such as football, golf, ballet, and weight lifting.

Exercises performed after a simple diskectomy do not seem to provide much added benefit over time.

Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although patients often find it difficult to maintain therapy.

Exercise and Acute or Subacute Back Pain

Exercise does not help acute back pain. In fact, overexertion may cause further harm. Beginning after 4 – 8 weeks of pain, however, a rehabilitation program may benefit the patient.

An incremental aerobic exercise program (such as walking, stationary biking, and swimming) may begin within 2 weeks of symptoms. Jogging is usually not recommended, at least not until the pain is gone and muscles are stronger.

Patients should avoid exercises that put the lower back under pressure until the back muscles are well toned. Such exercises include leg lifts done in a facedown position, straight leg sit-ups, and leg curls using exercise equipment.

In all cases, patients should never force themselves to exercise if, by doing so, the pain increases.

Exercise and Chronic Back Pain

Exercise plays a very beneficial role in chronic back pain. Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support and neutralize the spine. Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but also alter and improve patients’ attitudes toward their disability and pain. Exercise may also be effective when combined with a psychological and motivational program, such as cognitive-behavioral therapy.

There are different types of back pain exercises. Stretching exercises work best for reducing pain, while strengthening exercises are best for improving function.

Exercises for back pain include:

Low Impact Aerobic Exercises. Low-impact aerobic exercises, such as swimming, bicycling, and walking can strengthen muscles in the abdomen and back without over-straining the back. Programs that use strengthening exercises while swimming may be a particularly beneficial approach for many patients with back pain. Medical research has shown that pregnant women who engaged in a water gymnastics program have less back pain and are able to continue working longer.
Spine Stabilization and Strength Training. Exercises called lumbar extension strength training are proving to be effective. Generally, these exercises attempt to strengthen the abdomen, improve lower back mobility, strength, and endurance, and enhance flexibility in the hip, the hamstring muscles, and the tendons at the back of the thigh.
Yoga, Tai Chi, Chi Kung. Practices originating in Asia that combine low-impact physical movements and meditation may be very helpful. They are designed to achieve a physical and mental balance and can be very helpful in preventing recurrences of low back pain.
Flexibility Exercises. Flexibility exercises may help reduce pain. A stretching program may work best when combined with strengthening exercises.

Specific Exercises for Low Back Strength

Perform the following exercises at least three times a week:

Partial Sit-ups. Partial sit-ups or crunches strengthen the abdominal muscles.

Keep the knees bent and the lower back flat on the floor while raising the shoulders up 3 – 6 inches.
Exhale on the way up, and inhale on the way down.
Perform this exercise slowly 8 – 10 times with the arms across the chest.

Pelvic Tilt. The pelvic tilt alleviates tight or fatigued lower back muscles.

Lie on the back with the knees bent and feet flat on the floor.
Tighten the buttocks and abdomen so that they tip up slightly.
Press the lower back to the floor, hold for one second, and then relax.
Be sure to breathe evenly.

Over time increase this exercise until it is held for 5 seconds. Then, extend the legs a little more so that the feet are further away from the body and try it again.

Stretching Lower-Back Muscles. The following are three exercises for stretching the lower back:

Lie on the back with knees bent and legs together. Keeping arms at the sides, slowly roll the knees over to one side until totally relaxed. Hold this position for about 20 seconds (while breathing evenly) and then repeat on the other side.
Lying on the back, hold one knee and pull it gently toward the chest. Hold for 20 seconds. Repeat with the other knee.
While supported on hands and knees, lift and straighten right hand and left leg at the same time. Hold for 3 seconds while tightening the abdominal muscles. The back should be straight. Alternate with the other arm and leg and repeat on each side 8 – 20 times.

Note: No one with low back pain should perform exercises that require bending over right after getting up in the morning. At that time, the disks are more fluid-filled and more vulnerable to pressure from this movement.

Surgery and Invasive Procedures

The health care provider should give patients solid information on the expected course of their low back pain and self-care options before discussing surgery. Patients should ask their health care provider about evidence favoring surgery or other (nonsurgical) treatments in their particular case. They should also ask about the long-term outcome of the recommended treatment. Would the improvements last and, if so, for how long? Another consideration when surgery is an option is the overall safety of the recommended procedure, weighed against its potential short-term benefits and its benefits in the long run.

Patients should generally try all possible non-surgical treatments before opting for surgery. The most common reasons for surgery for low back pain are disk herniation and spinal stenosis. The vast majority of back pain patients will not need aggressive medical or surgical treatments.

Nevertheless, when it is appropriate, surgery can provide great relief. Many approaches and procedures are available or being investigated. However, there have been few well-conducted studies to determine if any type of back pain surgery works better than others, or if a single procedure is better than no surgery at all.

It should be noted that surgery does not always improve outcome and, in some cases, can even make it worse. Surgery can be an extremely effective approach, however, for certain patients whose severe back pain does not respond to conservative measures.

Diskectomy

Diskectomy is the surgical removal of the diseased disk. The procedure relieves pressure on the spine. It has been performed for 40 years, and increasingly less invasive techniques developed over time. However, few studies have been conducted to determine the procedure’s real effectiveness. In appropriate candidates it provides faster relief than medical treatment, but long-term benefits (over 5 years) are uncertain.

Diskectomy is recommended when a herniated disk causes one or more of the following:

Leg pain or numbness that are severe or persistent, making it hard for the patient to perform daily tasks
Weakness in the muscles of the lower leg or buttocks
An inability to control bowel movements or urination

Most other people with low back or neck pain, numbness, or even mild weakness are often first treated without surgery. Often, many of the symptoms of low back pain caused by a herniated disc get better or disappear over time, without surgery.

When the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of a disk, it is called a slipped disk. Most slipped disks (herniated disks) take place in the lumbar area of the spine. Slipped disks are one of the most common causes of lower back pain. The mainstay of treatment is an initial period of rest with pain and anti-inflammatory medications followed by physical therapy. If pain and symptoms persist, surgery to remove the herniated portion of the intervertebral disk may be needed.

Microdiskectomy. Microdiskectomy is the current standard procedure. It is performed through a small incision (1 to 1-1/2 inch). The back muscles are lifted and moved away from the spine. After identifying and moving the nerve root, the surgeon removes the injured disk tissue under it. The procedure does not change any of the structural supports of the spine, including joints, ligaments, and muscles.

Other, less invasive procedures are available, including endoscopic diskectomy, percutaneous diskectomy (PAD), and laser diskectomy. The long-term benefits are of these procedures are unknown, however. There is currently no evidence that any of these less-invasive procedures are as effective as the standard microdiskectomy.

Complications and Outlook. Most people achieve pain relief and can move better after microdiskectomy. Numbness and tingling should get better or disappear. Your pain, numbness, or weakness may NOT get better or go away if the disk damaged your nerve before surgery.

Scar tissue is a potential problem, since it can cause persistent low back pain afterward Other complications of spinal surgery can include nerve and muscle damage, infection, and the need for another operation.

Patients are usually up and walking soon after disk surgery. It may take 4 – 6 weeks for full recovery, however. Gentle exercise may be recommended at first. Starting intensive exercise 4 – 6 weeks after a first-time disk surgery appears to be very helpful for speeding up recovery. Little or no physical therapy is usually needed.

Laminectomy

Laminectomy is surgery to remove either the lamina, two small bones that make up a vertebra, or bone spurs in your back. Laminectomy opens up your spinal canal so your spinal nerves or spinal cord have more room. It is often done along with a diskectomy, foraminotomy, and spinal fusion.

Laminectomy is frequently done to treat spinal stenosis. You and your doctor can decide when you need to have surgery for your condition. Spinal stenosis symptoms often become worse over time, but this may happen very slowly. When your symptoms become more severe and interfere with your daily life or your job, surgery may help.

Laminectomy for spinal stenosis will often provide full or partial relief of symptoms for many patients, but it is not always successful

Future spine problems are possible for all patients after spine surgery. If you had spinal fusion and laminectomy, the spinal column above and below the fusion are more likely to have problems in the future. If you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future problems.

Click the icon to see an illustrated series detailing lumbar spinal surgery.

Some recurrence of back pain and sciatica occurs in half to two-thirds of postoperative patients. Minimally invasive variations are under investigation. For spinal stenosis, the traditional approach is a laminectomy and partial removal of the facet joint. There is controversy whether performing a fusion procedure along with these procedures is needed. Only a few randomized trials have compared this procedure with nonoperative treatment. Their results suggest that surgical treatment is better, at least over the first 2 years after surgery.

Spinal Fusion

Spinal fusion is surgery to fuse spine bones (vertebrae) that cause you to have back problems. Fusing means two bones are permanently placed together so there is no longer movement between them.

Spinal fusion is usually done along with other surgical procedures of the spine, such as a diskectomy, laminectomy, or a foraminotomy. It is done to prevent any movement in a certain area of the spine.

Conditions fusion may be done for include:

Spinal stenosis
Injury or fractures to the bones in the spine
Weak or unstable spine caused by infections or tumors
Spondylolisthesis, a condition in which one vertebrae slips forward on top of another
Abnormal curvatures, such as those from scoliosis or kyphosis

The surgeon will use a graft (such as bone) to hold (or fuse) the bones together permanently. There are several different ways of fusing vertebrae together:

Strips of bone graft material may be placed over the back part of the spine.
Bone graft material may be placed between the vertebrae
Special cages may be placed between the vertebrae. These cages are packed with bone graft material.

The surgeon may get the graft from different places:

From another part of your body (usually around your pelvic bone). This is called an autograft. Your surgeon will make a small cut over your hip and remove some bone from the back of the rim of the pelvis.
From a bone bank, in a procedure called an allograft.
A synthetic bone substitute can also be used, but this is not common yet.

The vertebrae are often also fixed together with screws, plates, or cages. These are used to keep the vertebrae from moving until the bone grafts fully heal.

Future spine problems are possible for all patients after spine surgery. After spinal fusion, the area that was fused together can no longer move. Therefore, the spinal column above and below the fusion is more likely to be stressed when the spine moves, and develop problems later on. Also, if you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may have more of a chance of future back problems.

Click the icon to see an illustrated series detailing spinal fusion.

There are currently a number of video-assisted fusion techniques. These new techniques are less invasive than standard “open” surgical approaches, which use wide incisions. To date, however, the newer procedures have higher complication rates than the open approaches, and some medical centers have abandoned them.

Other Surgical Procedures

Percutaneous Vertebroplasty. Percutaneous vertebroplasty involves the injection of a cement-like bone substitute into vertebrae with compression fractures. It is done under endoscopic and x-ray guidance. The technique is proving useful for stabilizing the spine and relieving pain in patients with spinal compression fractures due to osteoporosis or cancer.

Warning: The Food and Drug Administration (FDA) has warned consumers that polymethylmethacrylate bone cement, used during vertebroplasty, could leak. Such leakage could cause damage to soft tissues and nerves. It is extremely important that the patient is sure that the health care provider has had significant experience performing the vertebroplasty procedure.

Percutaneous kyphoplasty. The health care provider injects bone cement into the space surrounding a fractured vertebra. (Vertebroplasty injects the cement directly into the vertebra.) Kyphoplasty is used to stabilize the spine and return spinal height to as normal as possible. Kyphoplasty should only be done if bed rest, medicines, and physical therapy do not relieve back pain. Those with severe fractures or spinal infections should not have kyphoplasty.

Artificial Disk Replacement. Total disk replacement is an investigative procedure for some patients with severely damaged disks. It is done instead of spinal fusion surgery, but has not yet been shown to be superior to it. The technique implants artificial disks (ProDisc, Link, SB Charite) consisting of two metal plates and a soft core. The surgery can be performed using a minimally invasive laparoscopic procedure, which is performed through tiny cuts using miniature tools and viewing devices. An artificial cushioning device called the prosthetic disk nucleus (PDN) replaces only the inner gel-like core (nucleus pulposus) within the intervertebral space, rather than the entire disk. . A possible benefit of these artificial disks is that they would allow more movement of the spine, and therefore prevent disk degeneration below and above the site of surgery (a frequent complication of spinal fusion). This benefit has not been yet been proven in large studies.

Intradiscal Electrothermal Treatment (IDET). Intradiscal electrothermal treatment (IDET) uses electricity to heat a painful disk. Heat is applied for about 15 minutes. Pain may temporarily feel worse, but after healing, the disk shrinks and becomes desensitized to pain. However, healing takes several weeks. While some studies have reported benefit, many consider the evidence to support the use of this procedure weak.

Prognosis

Most people with acute low back pain are back at work within a month and fully recover within a few months. According to one study, about a third of patients with uncomplicated low back pain significantly improved after a week; two-thirds recovered by 7 weeks.

However, studies now suggest that up to 75% of patients suffer at least one recurrence of back pain over the course of a year. After 4 years, fewer than half of patients may be symptom-free. Some doctors are approaching the problem as one that is not necessarily curable and that needs a consistent on-going approach.

Specific conditions can determine the rate of improvement. For example:

In the majority of patients with herniated disks, the condition improves (although the actual physical improvement may be slower than the reduction in pain). Researchers attempted to identify factors most likely to predict an elevated risk for recurrent pain and found that only depression was a significant factor in the majority of those who had not recovered.
Spinal stenosis stabilizes in about 70% of cases and worsens in 15%.

Prevention and Self-Care

Most patients should understand that they are likely to improve over the first month after their low back pain begins, often with no treatments.

Home Care Tips for Relieving Pain

Resume normal activity as soon as possible. Bed rest is no longer recommended and may delay recovery. Activities should be done without strain or stretching.
Avoid intense exercise and physical activity, particularly heavy lifting and trunk twisting, if there is acute back pain.
Try an over-the-counter nonsteroidal anti-inflammatory such as aspirin or ibuprofen. These medicines often provide significant benefits.
Apply heat (104° F) to the painful area. Heat may work better than ibuprofen or acetaminophen. One group of researchers found that people with low back pain who wear low-level heat wraps for 8 hours a day have significantly less pain and disability.
Try alternating between hot and cold packs. Some doctors recommend changing from hot to cold every 3 minutes and repeating this sequence three times. Others believe ice packs should be applied first. This routine should be done two or three times during the day. (Note: Heat or cold treatments do not have much effect on sciatica.)
Supportive back belts, braces, or corsets may help some people temporarily, but these products can reduce muscle tone over time and should be used only briefly.
Get plenty of sleep. Healthy sleep plays a vital role in recovery. Avoid caffeine in the afternoon and evening, and unwind before bed by taking a warm bath or practicing relaxation techniques. It is often difficult to get a good night’s sleep when suffering from back pain, particularly because the pain can intensify at night. Some people may need medicine to help manage nighttime pain or treat sleeplessness. Lying curled up in a fetal position with a pillow between the knees or lying on the back with a pillow under the knees may help.
Yoga relieves low back pain better than conventional exercise or self-help books, according to a study published in the Annals of Internal Medicine. For the study, 101 adults with low back pain were randomly assigned to one of three groups. One group attended yoga classes and lessons; the second did aerobics, weight training, and stretching; the third group read a self-help book about back pain. After 12 weeks, those who took yoga could better perform daily activities requiring the back than those in the other two groups. After 26 weeks, those who took yoga had less pain and better back function, and used fewer pain relievers than the others.
Exercise, diet, stress, and weight all have a significant influence on back pain. Changing certain lifestyle factors can help reduce, and possibly prevent, backaches.

Quit Smoking

Smokers are at higher risk for back problems, perhaps because smoking decreases blood circulation. The link may also be due to an unhealthy lifestyle in general. A British study found that young adults who were long-term smokers were nearly twice as likely to develop low back pain as nonsmokers were.

Exercise and Obesity

Sedentary Lifestyle. People who do not exercise regularly face an increased risk for low back pain, especially when they perform sudden, stressful activities such as shoveling, digging, or moving heavy items. Although no definitive studies have been done to prove the relationship between lack of exercise and low back pain, some doctors believe that an inactive lifestyle may be to blame in some cases. Lack of exercise leads to the following conditions that may threaten the back:

Stiff muscles can make it hard to move, rotate, and bend the back.
Weak stomach muscles can increase the strain on the back and cause an abnormal tilt of the pelvis.
Weak back muscles may increase the risk for disk compression.
Obesity puts more weight on the spine and increases pressure on the vertebrae and disks. However, studies report only a weak association between obesity and low back pain.

Improper or Intense Exercise. Improper or excessive exercise may also increase one’s chances for back pain.

Some research suggests that over time, high-impact exercise may increase the risk for degenerative disk disease. A survey of people who played tennis, however, found no increased risk for low back pain or sciatica.
Between 30 – 70% of cyclists experience low back pain. One study reported that 70% of cyclists reported improvement simply by adjusting the angle of the bicycle seat.
Improper exercise instruction and inattention to body movements can lead to back trouble. For example, a single jerky golf swing or incorrect use of exercise equipment (especially free weights, nautilus, and rowing machines) can cause serious back injuries.

Tips for Daily Movement and Inactivity

The way a person moves, stands, or sleeps plays a major role in back pain.

Maintaining good posture is very important. This means keeping the ears, shoulders, and hips in a straight line with the head up and stomach pulled in. It is best not to stand for long periods of time. If it is necessary, walk as much as possible and wear shoes without heels, preferably with cushioned soles. Use a low foot stool and alternate resting each foot on top of it.
Sitting puts the most pressure on the back. Chairs should either have straight backs or low-back support. If possible, chairs should swivel to avoid twisting at the waist, have arm rests, and adjustable backs. While sitting, the knees should be a little higher than the hip, so a low stool or hassock is useful to put the feet on. A small pillow or rolled towel behind the lower back helps relieve pressure while either sitting or driving.
Riding in or driving a car for long periods of time increases stress. Move the car seat as far forward as possible to avoid bending forward. The back of the seat should not be reclined more than 30 degrees. If possible, the seat bottom should be tilted slightly upward in front. A traveler should stop and walk around about every hour. Avoid lifting or carrying objects immediately after the ride.
A common cause of temporary back pain in children is carrying backpacks that are too heavy. Backpacks should not weigh more than 20% of the child’s body weight. They should weigh even less for very young children. Emotional or behavioral problems may also contribute to back pain in children.

Tips for Lifting and Bending

Anyone who engages in heavy lifting should take precautions when lifting and bending.

If an object is too heavy or awkward, get help.
Spread your feet apart to give yourself a wide base of support.
Stand as close as possible to the object being lifted.
Bend at the knees, not at the waist. As you move up and down, tighten stomach muscles and tuck buttocks in so that the pelvis is rolled under and the spine remains in a natural “S’ curve. (Even when not lifting an object, always try to use this posture when stooping down.)
Hold objects close to the body to reduce the load on the back.
Lift using the leg muscles, not those in the back.
Stand up without bending forward from the waist.
Never twist from the waist while bending or lifting any heavy object. If you need to move an object to one side, point your toes in that direction and pivot toward it.
If an object can be moved without lifting, pull it, don’t push.

There are four natural curves in the spinal column: the cervical, thoracic, lumbar, and sacral curvature. The curves, along with the intervertebral disks, help to absorb and distribute stresses that occur from everyday activities such as walking or from more intense activities such as running and jumping.

Resources

www.niams.nih.gov — National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.aaos.org — American Academy of Orthopaedic Surgeons
www.arthritis.org — Arthritis Foundation
www.spine.org — North American Spine Society
www.apta.org — American Physical Therapy Association
www.ampainsoc.org — American Pain Society
www.theacpa.org — American Chronic Pain Association
www.iasp-pain.org — International Association for the Study of Pain

References

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Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-514.

Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 147(7):492-504.

Chou R, Qaseem A, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.

Clarke JA, van Tulder MW, Blomberg SE, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2007;(2):CD003010.

Curlee PM. Other Disorders of the Spine. In: Canale ST, Beatty JH. (eds.) Campbell’s Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007.

Erdogmus CB, Resch KL, Sabitzer R, et al. Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial. Spine. 2007;32(19):2041-2049.

Freeman BJ, Davenport J. Total disc replacement in the lumbar spine: a systematic review of the literature. Eur Spine J. 2006;15 Suppl 3:S439-47.

Freeman BJ. IDET: a critical appraisal of the evidence. Eur Spine J. 2006;15 Suppl 3:S448-457.

Freeman BJ, Fraser RD, Cain CM, et al. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. 2005;30(21):2369-77; discussion 2378.

Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007;167(17):1892-1898.

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Hayden JA, van Tulder MW, Malmivaara AV, et al. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142(9):765-775.

Johnson RE, Jones GT, Wiles NJ, et al. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine. 2007;32(15):1578-1585

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Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007;75(8):1181-8.

Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine. 20041;29(1):79-86.

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Pneumaticos SG, Chatziioannou SN, Hipp JA, et al. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology. 2006;238(2):693-698.

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ptsd resources

faithful — Sun, 22 Mar 2009 13:20:53 +0000

The PTSD Trap – Extras (sources, links, a bit of multimedia)

Category:
Posted on: March 16, 2009 11:02 AM, by David Dobbs

Below are materials supplementing my story “The Post-Traumatic Stress Trap,” Scientific American, April 2009. (You can find the story here and my blog post introducing it here.) I’m starting with annotated sources, source materials, and a bit of multimedia. I hope to add a couple sidebars that didn’t fit in the main piece — though those may end up at the main blog, so you may want to keep an eye there or subscribe via RSS or Atom.

Main sources and documents in “The Post-Traumatic Stress Trap.”

These are organized by story section, roughly in the order the relevant material appears. Quoted passages are from the article, with source material following.

- Introduction-

• Harvard psychology professor Richard J. McNally’s, “Progress and Controversy in the Study of Posttraumatic Stress Disorder [pdf download],” Annual Rev Psychology 2003:229-52, As the story notes, the PTSD debate has been going on a while now — since the PTSD diagnosis’ creation in the late 1970s — but was fanned into heat in 2003 by this long review essay by McNally.

“This critique, which was originally raised by military historians and a few psychologists, is now being pushed by a broad array of experts…” These have appeared in many venues, but are presented together most comprehensively in Gerald Rosen’s (ed) 2004 Posttraumatic Stress Disorder: Issues and Controversies (also in a Kindle edition and in a special 2007 issue of the Journal of Anxiety Disorders.

• The 1990 National Vietnam Veterans Readjustment Survey, which surveyed over 1,000 Vietnam veterans in 1988 and found that 15.2 percent of them had PTSD then and 30.9 percent had suffered it at some point since the war, is a key document in the PTSD debate. It established the canonical rate estimates — but came under fire almost immediately for not confirming cases and for rate estimates some historians and diagnosticians thought unrealistically high. Its findings are summarized nicely here by Jennifer Price at the VA’s National Center for PTSD.

• In “The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods in Science in August 2006, Columbia University epidemiologist Bruce Dohrenwend and others, hoping to resolve the debate about the NVVRS, presented a reanalysis of the original NVVRS data. They found that the 1988 rate was 9.1 percent and the lifetime rate 18.7 percent — 40 percent drops from the original. Both sides claimed these findings proved their case. The PTSD establishment said the study supported the construct’s basic integrity by confirming most cases and showing a dose-response relationship. Critics said it proved that this seminal 1990 study had overstated Vietnam veterans’ PTSD rates.

• McNally’s “Psychiatric Casualties of War,” presented alongside Dohrenwend’s study in Science, stressed how sharply Dohrenwend’s revision cut the canonical rates established by the NVVRS — and argued that applying standard clinical defintions of impairment would cut the rates even further. The letters section that follows these pieces online gives a good picture of the academic dispute that flared up afterwards.

It was that exchange that drew my attention to the controversy; as editor of Scientific American’s Mind Matters blog, I solicited “The Costs of War,”, a pair of commentaries on the controversy — one by McNally, one by William Schlenger and Charles Marmar — that ran in Mind Matters in the fall of 2007. (Apologies for the post’s present formatting; it did not fare well in sciam.com’s later website overhaul.)

The flap in Science also led to a special, hastily called symposium at the November 2006 annual meeting of the International Society for Traumatic Stress Studies (ISTSS), which featured presentations by Dohrenwend; Terry Keane, a leading PTSD researcher and clinician at the Boston VA; then-ISTSS president Dean Kilpatrick, who is is a PTSD researcher and clinician at the Medical University of South Carolina; and — via an 8-minute presentation delivered via DVD, as he was in Europe on a previous commitment — Richard McNally.

I am hoping to secure ISTSS’s permission to place here an audio recording of the entire symposium. McNally’s video presentation, however, is viewable below.

(It was this presentation that led Kilpatrick to “essentially call McNally a liar,” as I said in the piece. Specifically, after McNally’s presentation aired, Kilpatrick took the floor (it was his turn) and said, “What I would like to do is swear Rich McNally in under oath to tell the truth, the whole truth, and nothing but the truth. If that were done, I think you’d have seen an entirely different presentation.” Kilpatrick later said he meant not that McNally lied, but that he failed to present the entire story — an odd thing to ask, as one observer noted, of an 8-minute presentation)

- A Problematic Diagnosis -

The fourth Diagnostic Statistical Manual (DSM-IV) provides the present diagnostic definition and guidelines for PTSD. This is updated somewhat from the original construct presented in the 1978 DSM-III.

On the reliability of memory: Elizabeth Loftus’s “Creating False Memories,” from Scientific American, Sept 1997, describes how malleable memory can be, as does Daniel Schacter’s Seven Sins of Memory. McNally’s book Remembering Trauma gives a fuller, more trauma-specific account of memory’s foibles. The “1990 study at the West Haven VA Hospital” that explored malleability of memories in veterans of the 1990 Gulf War is by “Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm, ” by Southwick and others.

On PTSD’s endocrinology:Rachel Yehuda’s “Biology of posttraumatic stress disorder,” from 2001, is one of several studies that found evidence of neuroendocrinological pecularities in PTSD; a 2004 study by Lindsey et alia’s is one of several that did not. On the search for correlates of PTSD detectable through brain imaging, see Francati, Vermetten, and Bremner, “Functional neuroimaging studies in posttraumatic stress disorder: review of current methods and findings,” 2006.

On the ties between trauma and PTSD symptoms,: see the Bodkin, Pope, and Hudson study described in the article, “Is PTSD caused by traumatic stress,” which found zero correlation between PTSD diagnoses made by symptom clusters and those made by trauma histories.

“The most effective PTSD treatment is exposure-based cognitive behavioral therapy” – This is asserted by many experts and authorities, including a comprehensive review by a National Academy of Science committee, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2007).

The symptom overlap between PTSD and traumatic brain injury is explored, among other places, in Hoge et alia’s “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq,” New England J of Medicine, 31 Jan 2008.

- Disabling Conditions -

“In civilian populations, two-thirds of PTSD patients respond to treatment.” from, e.g, “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” Am J Psychiatry 162 (Feb 2005) (Search for “Across all treatments”)

“…most veterans getting PTSD treatment from the VA report worsening symptoms until they reach 100 percent disability — at which point their use of VA mental health services drops 82 percent.” From VA Office of Inspector General, “Review of State Variances in VA Disability Compensation Payments” [large download] (Report VAOIG-05-00765-137), May 2005, p ix.

“… although the risk of PTSD from a traumatic event drops as time passes, the number of Vietnam veterans applying for PTSD disability almost doubled between 1999 and 2004, driving total PTSD disability payments to over $4 billion annually.” from Veterans Compensation for Posttraumatic Stress Disorder, Institute of Medicine and National Research Council PTSD Compensation and Military Service, National Academics Press, 2005.

The innovative disability program used in Australia is described here.

- Two Ways to Carry a Rifle –

Finally, the conflicting studies of PTSD in US veterans of the Iraq and Afghanistan wars cited in the piece are Milliken et alia, “Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War,” JAMA 14 Nov 2007, which found rates of around 20%, and Smith et al, “New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study,” BMJ 16 Feb 2008, which found rates of under 5%.

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