Back Clinic Health Team. The level of functional and metabolic efficiency of a living organism. In humans, it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological, and social changes in an environment. Dr.Alex Jimenez D.C., C.C.S.T, a clinical pain doctor who uses cutting-edge therapies and rehabilitation procedures focused on total health, strength training, and complete conditioning. We take a global functional fitness treatment approach to regain complete functional health.
Dr. Jimenez presents articles both from his own experience and from a variety of sources that pertain to a healthy lifestyle or general health issues. I have spent over 30+ years researching and testing methods with thousands of patients and understand what truly works. We strive to create fitness and better the body through researched methods and total health programs.
These programs and methods are natural and use the body’s own ability to achieve improvement goals, rather than introducing harmful chemicals, controversial hormone replacement, surgery, or addictive drugs. As a result, individuals live a fulfilled life with more energy, a positive attitude, better sleep, less pain, proper body weight, and education on maintaining this way of life.
Degenerative Disc Disease is a general term for a condition in which the damaged intervertebral disc causes chronic pain, which could be either low back pain in the lumbar spine or neck pain in the cervical spine. It is not a �disease� per se, but actually a breakdown of an intervertebral disc of the spine. The intervertebral disc is a structure that has a lot of attention being focused on recently, due to its clinical implications. The pathological changes that can occur in disc degeneration include fibrosis, narrowing, and disc desiccation. Various anatomical defects can also occur in the intervertebral disc such as sclerosis of the endplates, fissuring and mucinous degeneration of the annulus, and the formation of osteophytes.
Low back pain and neck pain are major epidemiological problems, which are thought to be related to degenerative changes in the disk. Back pain is the second leading cause of the visit to the clinician in the USA. It is estimated that about 80% of US adults suffer from low back pain at least once during their lifetime. (Modic, Michael T., and Jeffrey S. Ross) Therefore, a thorough understanding of degenerative disc disease is needed for managing this common condition.
Anatomy of Related Structures
Anatomy of the Spine
The spine is the main structure, which maintains the posture and gives rise to various problems with disease processes. The spine is composed of seven cervical vertebrae, twelve thoracic vertebrae, five lumbar vertebrae, and fused sacral and coccygeal vertebrae. The stability of the spine is maintained by three columns.
The anterior column is formed by anterior longitudinal ligament and the anterior part of the vertebral body. The middle column is formed by the posterior part of the vertebral body and the posterior longitudinal ligament. The posterior column consists of a posterior body arch that has transverse processes, laminae, facets, and spinous processes. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology�)
Anatomy of the Intervertebral Disc
Intervertebral disc lies between two adjacent vertebral bodies in the vertebral column. About one-quarter of the total length of the spinal column is formed by intervertebral discs. This disc forms a fibrocartilaginous joint, also called a symphysis joint. It allows a slight movement in the vertebrae and holds the vertebrae together. Intervertebral disc is characterized by its tension resisting and compression resisting qualities. An intervertebral disc is composed of mainly three parts; inner gelatinous nucleus pulposus, outer annulus fibrosus, and cartilage endplates that are located superiorly and inferiorly at the junction of vertebral bodies.
Nucleus pulposus is the inner part that is gelatinous. It consists of proteoglycan and water gel held together by type II Collagen and elastin fibers arranged loosely and irregularly. Aggrecan is the major proteoglycan found in the nucleus pulposus. It comprises approximately 70% of the nucleus pulposus and nearly 25% of the annulus fibrosus. It can retain water and provides the osmotic properties, which are needed to resist compression and act as a shock absorber. This high amount of aggrecan in a normal disc allows the tissue to support compressions without collapsing and the loads are distributed equally to annulus fibrosus and vertebral body during movements of the spine. (Wheater, Paul R, et al.)
The outer part is called annulus fibrosus, which has abundant type I collagen fibers arranged as a circular layer. The collagen fibers run in an oblique fashion between lamellae of the annulus in alternating directions giving it the ability to resist tensile strength. Circumferential ligaments reinforce the annulus fibrosus peripherally. On the anterior aspect, a thick ligament further reinforces annulus fibrosus and a thinner ligament reinforces the posterior side. (Choi, Yong-Soo)
Usually, there is one disc between every pair of vertebrae except between atlas and axis, which are first and second cervical vertebrae in the body. These discs can move about 6? in all the axes of movement and rotation around each axis. But this freedom of movement varies between different parts of the vertebral column. The cervical vertebrae have the greatest range of movement because the intervertebral discs are larger and there is a wide concave lower and convex upper vertebral body surfaces. They also have transversely aligned facet joints. Thoracic vertebrae have the minimum range of movement in flexion, extension, and rotation, but have free lateral flexion as they are attached to the rib cage. The lumbar vertebrae have good flexion and extension, again, because their intervertebral discs are large and spinous processes are posteriorly located. However, lateral lumbar rotation is limited because the facet joints are located sagittally. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology�)
Blood Supply
The intervertebral disc is one of the largest avascular structures in the body with capillaries terminating at the endplates. The tissues derive nutrients from vessels in the subchondral bone which lie adjacent to the hyaline cartilage at the endplate. These nutrients such as oxygen and glucose are carried to the intervertebral disc through simple diffusion. (�Intervertebral Disc � Spine � Orthobullets.Com�)
Nerve Supply
Sensory innervation of intervertebral discs is complex and varies according to the location in the spinal column. Sensory transmission is thought to be mediated by substance P, calcitonin, VIP, and CPON. Sinu vertebral nerve, which arises from the dorsal root ganglion, innervates the superficial fibers of the annulus. Nerve fibers don�t extend beyond the superficial fibers.
Lumbar intervertebral discs are additionally supplied on the posterolateral aspect with branches from ventral primary rami and from the grey rami communicantes near their junction with the ventral primary rami. The lateral aspects of the discs are supplied by branches from rami communicantes. Some of the rami communicantes may cross the intervertebral discs and become embedded in the connective tissue, which lies deep to the origin of the psoas. (Palmgren, Tove, et al.)
The cervical intervertebral discs are additionally supplied on the lateral aspect by branches of the vertebral nerve. The cervical sinu vertebral nerves were also found to be having an upward course in the vertebral canal supplying the disc at their point of entry and the one above. (BOGDUK, NIKOLAI, et al.)
Pathophysiology of Degenerative Disc Disease
Approximately 25% of people before the age of 40 years show disc degenerative changes at some level. Over 40 years of age, MRI evidence shows changes in more than 60% of people. (Suthar, Pokhraj) Therefore, it is important to study the degenerative process of the intervertebral discs as it has been found to degenerate faster than any other connective tissue in the body, leading to back and neck pain. The changes in three intervertebral discs are associated with changes in the vertebral body and joints suggesting a progressive and dynamic process.
The degenerative process of the intervertebral discs has been divided into three stages, according to Kirkaldy-Willis and Bernard, called ��degenerative cascade��. These stages can overlap and can occur over the course of decades. However, identifying these stages clinically is not possible due to the overlap of symptoms and signs.
Stage 1 (Degeneration Phase)
This stage is characterized by degeneration. There are histological changes, which show circumferential tears and fissures in the annulus fibrosus. These circumferential tears may turn into radial tears and because the annulus pulposus is well innervated, these tears can cause back pain or neck pain, which is localized and with painful movements. Due to repeated trauma in the discs, endplates can separate leading to disruption of the blood supply to the disc and therefore, depriving it of its nutrient supply and removal of waste. The annulus may contain micro-fractures in the collagen fibrils, which can be seen on electron microscopy and an MRI scan may reveal desiccation, bulging of the disc, and a high-intensity zone in the annulus. Facet joints may show a synovial reaction and it may cause severe pain with associated synovitis and inability to move the joint in the zygapophyseal joints. These changes may not necessarily occur in every person. (Gupta, Vijay Kumar, et al.)
The nucleus pulposus is also involved in this process as its water imbibing capacity is reduced due to the accumulation of biochemically changed proteoglycans. These changes are brought on mainly by two enzymes called matrix metalloproteinase-3 (MMP-3) and tissue inhibitor of metalloproteinase-1 (TIMP-1). (Bhatnagar, Sushma, and Maynak Gupta) Their imbalance leads to the destruction of proteoglycans. The reduced capacity to absorb water leads to a reduction of hydrostatic pressure in the nucleus pulposus and causes the annular lamellae to buckle. This can increase the mobility of that segment resulting in shear stress to the annular wall. All these changes can lead to a process called annular delamination and fissuring in the annulus fibrosus. These are two separate pathological processes and both can lead to pain, local tenderness, hypomobility, contracted muscles, painful joint movements. However, the neurological examination at this stage is usually normal.
Stage 2 (Phase of Instability)
The stage of dysfunction is followed by a stage of instability, which may result from the progressive deterioration of the mechanical integrity of the joint complex. There may be several changes encountered at this stage, including disc disruption and resorption, which can lead to a loss of disc space height. Multiple annular tears may also occur at this stage with concurrent changes in the zagopophyseal joints. They may include degeneration of the cartilage and facet capsular laxity leading to subluxation. These biomechanical changes result in instability of the affected segment.
The symptoms seen in this phase are similar to those seen in the dysfunction phase such as �giving way� of the back, pain when standing for prolonged periods, and a �catch� in the back with movements. They are accompanied by signs such as abnormal movements in the joints during palpation and observing that the spine sways or shifts to a side after standing erect for sometime after flexion. (Gupta, Vijay Kumar et al.)
Stage 3 (Re-Stabilization Phase)
In this third and final stage, the progressive degeneration leads to disc space narrowing with fibrosis and osteophyte formation and transdiscal bridging. The pain arising from these changes is severe compared to the previous two stages, but these can vary between individuals. This disc space narrowing can have several implications on the spine. This can cause the intervertebral canal to narrow in the superior-inferior direction with the approximation of the adjacent pedicles. Longitudinal ligaments, which support the vertebral column, may also become deficient in some areas leading to laxity and spinal instability. The spinal movements can cause the ligamentum flavum to bulge and can cause superior aricular process subluxation. This ultimately leads to a reduction of diameter in the anteroposterior direction of the intervertebral space and stenosis of upper nerve root canals.
Formation of osteophytes and hypertrophy of facets can occur due to the alteration in axial load on the spine and vertebral bodies. These can form on both superior and inferior articular processes and osteophytes can protrude to the intervertebral canal while the hypertrophied facets can protrude to the central canal. Osteophytes are thought to be made from the proliferation of articular cartilage at the periosteum after which they undergo endochondral calcification and ossification. The osteophytes are also formed due to the changes in oxygen tension and due to changes in fluid pressure in addition to load distribution defects. The osteophytes and periarticular fibrosis can result in stiff joints. The articular processes may also orient in an oblique direction causing retrospondylolisthesis leading to the narrowing of the intervertebral canal, nerve root canal, and the spinal canal. (KIRKALDY-WILLIS, W H et al.)
All of these changes lead to low back pain, which decreases with severity. Other symptoms like reduced movement, muscle tenderness, stiffness, and scoliosis can occur. The synovial stem cells and macrophages are involved in this process by releasing growth factors and extracellular matrix molecules, which act as mediators. The release of cytokines has been found to be associated with every stage and may have therapeutic implications in future treatment development.
Etiology of the Risk Factors of Degenerative Disc Disease
Aging and Degeneration
It is difficult to differentiate aging from degenerative changes. Pearce et al have suggested that aging and degeneration is representing successive stages within a single process that occur in all individuals but at different rates. Disc degeneration, however, occurs most often at a faster rate than aging. Therefore, it is encountered even in patients of working age.
There appears to be a relationship between aging and degeneration, but no distinct cause has yet been established. Many studies have been conducted regarding nutrition, cell death, and accumulation of degraded matrix products and the failure of the nucleus. The water content of the intervertebral disc decreases with the increasing age. Nucleus pulposus can get fissures that can extend into the annulus fibrosus. The start of this process is termed chondrosis inter vertebralis, which can mark the beginning of the degenerative destruction of the intervertebral disc, the endplates, and the vertebral bodies. This process causes complex changes in the molecular composition of the disc and has biomechanical and clinical sequelae that can often result in substantial impairment in the affected individual.
The cell concentration in the annulus decreases with increasing age. This is mainly because the cells in the disc are subjected to senescence and they lose the ability to proliferate. Other related causes of age-specific degeneration of intervertebral discs include cell loss, reduced nutrition, post-translational modification of matrix proteins, accumulation of products of degraded matrix molecules, and fatigue failure of the matrix. Decreasing nutrition to the central disc, which allows the accumulation of cell waste products and degraded matrix molecules seems to be the most important change out of all these changes. This impairs nutrition and causes a fall in the pH level, which can further compromise cell function and may lead to cell death. Increased catabolism and decreased anabolism of senescent cells may promote degeneration. (Buckwalter, Joseph A.) According to one study, there were more senescence cells in the nucleus pulposus compared to annulus fibrosus and herniated discs had a higher chance of cell senescence.� (Roberts, S. et al.)
When the aging process goes on for some time, the concentrations of chondroitin 4 sulfate and chondroitin 5 sulfate, which is strongly hydrophilic, gets decreased while the keratin sulfate to chondroitin sulfate ratio gets increased. Keratan sulfate is mildly hydrophilic and it also has a minor tendency to form stable aggregates with hyaluronic acid. As aggrecan is fragmented, and its molecular weight and numbers are decreased, the viscosity and hydrophilicity of the nucleus pulposus decrease. Degenerative changes to the intervertebral discs are accelerated by the reduced hydrostatic pressure of the nucleus pulposus and the decreased supply of nutrients by diffusion. When the water content of the extracellular matrix is decreased, intervertebral disc height will also be decreased. The resistance of the disc to an axial load will also be reduced. Because the axial load is then transferred directly to the annulus fibrosus, annulus clefts can get torn easily.
All these mechanisms lead to structural changes seen in degenerative disc disease. Due to the reduced water content in the annulus fibrosus and associated loss of compliance, the axial load can get redistributed to the posterior aspect of facets instead of the normal anterior and middle part of facets. This can cause facet arthritis, hypertrophy of the adjacent vertebral bodies, and bony spurs or bony overgrowths, known as osteophytes, as a result of degenerative discs. (Choi, Yong-Soo)
Genetics and Degeneration
The genetic component has been found to be a dominant factor in degenerative disc disease. Twin studies, and studies involving mice, have shown that genes play a role in disc degeneration. (Boyd, Lawrence M., et al.) Genes that code for collagen I, IX, and XI, interleukin 1, aggrecan, vitamin D receptor, matrix metalloproteinase 3 (MMP � 3), and other proteins are among the genes that are suggested to be involved in degenerative disc disease. Polymorphisms in 5 A and 6 A alleles occurring in the promoter region of genes that regulate MMP 3 production are found to be a major factor for the increased lumbar disc degeneration in the elderly population. Interactions among these various genes contribute significantly to intervertebral disc degeneration disease as a whole.
Nutrition and Degeneration
Disc degeneration is also believed to occur due to the failure of nutritional supply to the intervertebral disc cells. Apart from the normal aging process, the nutritional deficiency of the disc cells is adversely affected by endplate calcification, smoking, and the overall nutritional status. Nutritional deficiency can lead to the formation of lactic acid together with the associated low oxygen pressure. The resulting low pH can affect the ability of disc cells to form and maintain the extracellular matrix of the discs and causes intervertebral disc degeneration. The degenerated discs lack the ability to respond normally to the external force and may lead to disruptions even from the slightest back strain. (Taher, Fadi, et al.)
Growth factors stimulate the chondrocytes and fibroblasts to produce more amount of extracellular matrix. It also inhibits the synthesis of matrix metalloproteinases. Example of these growth factors includes transforming growth factor, insulin-like growth factor, and basic fibroblast growth factor. The degraded matrix is repaired by an increased level of transforming growth factor and basic fibroblast growth factor.
Environment and Degeneration
Even though all the discs are of the same age, discs found in the lower lumbar segments are more vulnerable to degenerative changes than the discs found in the upper segment. This suggests that not only aging but, also mechanical loading, is a causative factor. The association between degenerative disc disease and environmental factors has been defined in a comprehensive manner by Williams and Sambrook in 2011. (Williams, F.M.K., and P.N. Sambrook) The heavy physical loading associated with your occupation is a risk factor that has some contribution to disc degenerative disease. There is also a possibility of chemicals causing disc degeneration, such as smoking, according to some studies. (Batti�, Michele C.) Nicotine has been implicated in twin studies to cause impaired blood flow to the intervertebral disc, leading to disc degeneration. (BATTI�, MICHELE C., et al.) Moreover, an association has been found among atherosclerotic lesions in the aorta and the low back pain citing a link between atherosclerosis and degenerative disc disease. (Kauppila, L.I.) The disc degeneration severity was implicated in overweight, obesity, metabolic syndrome, and increased body mass index in some studies. (�A Population-Based Study Of Juvenile Disc Degeneration And Its Association With Overweight And Obesity, Low Back Pain, And Diminished Functional Status. Samartzis D, Karppinen J, Mok F, Fong DY, Luk KD, Cheung KM. J Bone Joint Surg Am 2011;93(7):662�70�)
Pain in Disc Degeneration (Discogenic Pain)
Discogenic pain, which is a type of nociceptive pain, arises from the nociceptors in the annulus fibrosus when the nervous system is affected by the degenerative disc disease. Annulus fibrosus contains immune reactive nerve fibers in the outer layer of the disc with other chemicals such as a vasoactive intestinal polypeptide, calcitonin gene-related peptide, and substance P. (KONTTINEN, YRJ� T., et al.) When degenerative changes in the intervertebral discs occur, normal structure and mechanical load are changed leading to abnormal movements. These disc nociceptors can get abnormally sensitized to mechanical stimuli. The pain can also be provoked by the low pH environment caused by the presence of lactic acid, causing increased production of pain mediators.
Pain from degenerative disc disease may arise from multiple origins. It may occur due to the structural damage, pressure, and irritation on the nerves in the spine. The disc itself contains only a few nerve fibers, but any injury can sensitize these nerves, or those in the posterior longitudinal ligament, to cause pain. Micro movements in the vertebrae can occur, which may cause painful reflex muscle spasms because the disc is damaged and worn down with the loss of tension and height. The painful movements arise because the nerves supplying the area are compressed or irritated by the facet joints and ligaments in the foramen leading to leg and back pain. This pain may be aggravated by the release of inflammatory proteins that act on nerves in the foramen or descending nerves in the spinal canal.
Pathological specimens of the degenerative discs, when observed under the microscope, reveals that there are vascularized granulation tissue and extensive innervations found in the fissures of the outer layer of the annulus fibrosus extending into the nucleus pulposus. The granulation tissue area is infiltrated by abundant mast cells and they invariably contribute to the pathological processes that ultimately lead to discogenic pain. These include neovascularisation, intervertebral disc degeneration, disc tissue inflammation, and the formation of fibrosis. Mast cells also release substances, such as tumor necrosis factor and interleukins, which might signal for the activation of some pathways which play a role in causing back pain. Other substances that can trigger these pathways include phospholipase A2, which is produced from the arachidonic acid cascade. It is found in increased concentrations in the outer third of the annulus of the degenerative disc and is thought to stimulate the nociceptors located there to release inflammatory substances to trigger pain. These substances bring about axonal injury, intraneural edema, and demyelination. (Brisby, Helena)
The back pain is thought to arise from the intervertebral disc itself. Hence why the pain will decrease gradually over time when the degenerating disc stops inflicting pain. However, the pain actually arises from the disc itself only in 11% of patients according to endoscopy studies. The actual cause of back pain seems to be due to the stimulation of the medial border of the nerve and referred pain along the arm or leg seems to arise due to the stimulation of the core of the nerve. The treatment for disc degeneration should mainly focus on pain relief to reduce the suffering of the patient because it is the most disabling symptom that disrupts a patient�s lives. Therefore, it is important to establish the mechanism of pain because it occurs not only due to the structural changes in the intervertebral discs but also due to other factors such as the release of chemicals and understanding these mechanisms can lead to effective pain relief. (Choi, Yong-Soo)
Clinical Presentation of Degenerative Disc Disease
Patients with degenerative disc disease face a myriad of symptoms depending on the site of the disease. Those who have lumbar disc degeneration get low back pain, radicular symptoms, and weakness. Those who have cervical disc degeneration have neck pain and shoulder pain.
Low back pain can get exacerbated by the movements and the position. Usually, the symptoms are worsened by the flexion, while the extension often relieves them. Minor twisting injuries, even from swinging a golf club, can trigger the symptoms. The pain is usually observed to be less when walking or running, when changing the position frequently and when lying down. However, the pain is usually subjective and in many cases, it varies considerably from person to person and most people will suffer from a low level of chronic pain of the lower back region continuously while occasionally suffering from the groin, hip, and leg pain. The intensity of the pain will increase from time to time and will last for a few days and then subside gradually. This �flare-up� is an acute episode and needs to be treated with potent analgesics. Worse pain is experienced in the seated position and is exacerbated while bending, lifting, and twisting movements frequently. The severity of the pain can vary considerably with some having occasional nagging pain to others having severe and disabling pain intermittently.� (Jason M. Highsmith, MD)
The localized pain and tenderness in the axial spine usually arises from the nociceptors found within the intervertebral discs, facet joints, sacroiliac joints, dura mater of the nerve roots, and the myofascial structures found within the axial spine. As mentioned in the previous sections, the degenerative anatomical changes may result in a narrowing of the spinal canal called spinal stenosis, overgrowth of spinal processes called osteophytes, hypertrophy of the inferior and superior articular processes, spondylolisthesis, bulging of the ligamentum flavum and disc herniation. These changes result in a collection of symptoms that is known as neurogenic claudication. There may be symptoms such as low back pain and leg pain together with numbness or tingling in the legs, muscle weakness, and foot drop. Loss of bowel or bladder control may suggest spinal cord impingement and prompt medical attention is needed to prevent permanent disabilities. These symptoms can vary in severity and may present to varying extents in different individuals.
The pain can also radiate to other parts of the body due to the fact that the spinal cord gives off several branches to two different sites of the body. Therefore, when the degenerated disc presses on a spinal nerve root, the pain can also be experienced in the leg to which the nerve ultimately innervates. This phenomenon, called radiculopathy, can occur from many sources arising, due to the process of degeneration. The bulging disc, if protrudes centrally, can affect descending rootlets of the cauda equina, if it bulges posterolaterally, it might affect the nerve roots exiting at the next lower intervertebral canal and the spinal nerve within its ventral ramus can get affected when the disc protrudes laterally. Similarly, the osteophytes protruding along the upper and lower margins of the posterior aspect of vertebral bodies can impinge on the same nervous tissues causing the same symptoms. Superior articular process hypertrophy may also impinge upon nerve roots depending on their projection. The nerves may include nerve roots prior to exiting from the next lower intervertebral canal and nerve roots within the upper nerve root canal and dural sac. These symptoms, due to the nerve impingement, have been proven by cadaver studies. Neural compromise is thought to occur when the neuro foraminal diameter is critically occluded with a 70% reduction. Furthermore, neural compromise can be produced when the posterior disc is compressed less than 4 millimeters in height, or when the foraminal height is reduced to less than 15 millimeters leading to foraminal stenosis and nerve impingement. (Taher, Fadi, et al.)
Diagnostic Approach
Patients are initially evaluated with an accurate history and thorough physical examination and appropriate investigations and provocative testing. However, history is often vague due to the chronic pain which cannot be localized properly and the difficulty in determining the exact anatomical location during provocative testing due to the influence of the neighboring anatomical structures.
Through the patient�s history, the cause of low back pain can be identified as arising from the nociceptors in the intervertebral discs. Patients may also give a history of the chronic nature of the symptoms and associated gluteal region numbness, tingling as well as stiffness in the spine which usually worsens with activity. Tenderness may be elicited by palpating over the spine. Due to the nature of the disease being chronic and painful, most patients may be suffering from mood and anxiety disorders. Depression is thought to be contributing negatively to the disease burden. However, no clear relationship between disease severity and mood or anxiety disorders. It is good to be vigilant about these mental health conditions as well. In order to exclude other serious pathologies, questions must be asked regarding fatigue, weight loss, fever, and chills, which might indicate some other diseases. (Jason M. Highsmith, MD)
Another etiology for the low back pain has to be excluded when examining the patient for degenerative disc disease. Abdominal pathologies, which can give rise to back pain such as aortic aneurysm, renal calculi, and pancreatic disease, have to be excluded.
Degenerative disc disease has several differential diagnoses to be considered when a patient presents with back pain. These include; idiopathic low back pain, zygapophyseal joint degeneration, myelopathy, lumbar stenosis, spondylosis, osteoarthritis, and lumbar radiculopathy. (�Degenerative Disc Disease � Physiopedia�)
Investigations
Investigations are used to confirm the diagnosis of degenerative disc disease. These can be divided into laboratory studies, imaging studies, nerve conduction tests, and diagnostic procedures.
Imaging Studies
The imaging in degenerative disc disease is mainly used to describe anatomical relations and morphological features of the affected discs, which has a great therapeutic value in future decision making for treatment options. Any imaging method, like plain radiography, CT, or MRI, can provide useful information. However, an underlying cause can only be found in 15% of the patients as no clear radiological changes are visible in degenerative disc disease in the absence of disc herniation and neurological deficit. Moreover, there is no correlation between the anatomical changes seen on imaging and the severity of the symptoms, although there are correlations between the number of osteophytes and the severity of back pain. Degenerative changes in radiography can also be seen in asymptomatic people leading to difficulty in conforming clinical relevance and when to start treatment. (�Degenerative Disc Disease � Physiopedia�)
Plain Radiography
This inexpensive and widely available plain cervical radiography can give important information on deformities, alignment, and degenerative bony changes. In order to determine the presence of spinal instability and sagittal balance, dynamic flexion, or extension studies have to be performed.
Magnetic Resonance Imaging (MRI)
MRI is the most commonly used method to diagnose degenerative changes in the intervertebral disc accurately, reliably, and most comprehensively. It is used in the initial evaluation of patients with neck pain after plain radiography. It can provide non-invasive images in multiple plains and gives excellent quality images of the disc. MRI can show disc hydration and morphology-based on the proton density, chemical environment, and the water content. Clinical picture and history of the patient have to be considered when interpreting MRI reports as it has been shown that as much as 25% of radiologists change their report when the clinical data are available. Fonar produced the first open MRI scanner with the ability of the patient to be scanned in different positions such as standing, sitting, and bending. Because of these unique features, this open MRI scanner can be used for scanning patients in weight-bearing postures and stand up postures to detect underlying pathological changes which are usually overlooked in conventional MRI scan such as lumbar degenerative disc disease with herniation. This machine is also good for claustrophobic patients, as they get to watch a large television screen during the scanning process. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology.�)
Nucleus pulposus and annulus fibrosus of the disc can usually be identified on MRI, leading to the detection of disc herniation as contained and non contained. As MRI can also show annular tears and the posterior longitudinal ligament, it can be used to classify herniation. This can be simple annular bulging to free fragment disc herniations. This information can describe the pathologic discs such as extruded disc, protruded discs, and migrated discs.
There are several grading systems based on MRI signal intensity, disc height, the distinction between nucleus and annulus, and the disc structure. The method, by Pfirrmann et al, has been widely applied and clinically accepted. According to the modified system, there are 8 grades for lumbar disc degenerative disease. Grade 1 represents normal intervertebral disc and grade 8 corresponds to the end stage of degeneration, depicting the progression of the disc disease. There are corresponding images to aid the diagnosis. As they provide good tissue differentiation and detailed description of the disc structure, sagittal T2 weighted images are used for the classification purpose. (Pfirrmann, Christian W. A., et al.)
Modic has described the changes occurring in the vertebral bodies adjacent to the degenerating discs as Type 1 and Type 2 changes. In Modic 1 changes, there is decreased intensity of T1 weighted images and increased intensity T2 weighted images. This is thought to occur because the end plates have undergone sclerosis and the adjacent bone marrow is showing inflammatory response as the diffusion coefficient increases. This increase of diffusion coefficient and the ultimate resistance to diffusion is brought about by the chemical substances released through an autoimmune mechanism. Modic type 2 changes include the destruction of the bone marrow of adjacent vertebral endplates due to an inflammatory response and the infiltration of fat in the marrow. These changes may lead to increased signal density on T1 weighted images. (Modic, M T et al.)
Computed Tomography (CT)
When MRI is not available, Computed tomography is considered a diagnostic test that can detect disc herniation because it has a better contrast between posterolateral margins of the adjacent bony vertebrae, perineal fat, and the herniated disc material. Even so, when diagnosing lateral herniations, MRI remains the imaging modality of choice.
CT scan has several advantages over MRI such as it has a less claustrophobic environment, low cost, and better detection of bonny changes that are subtle and may be missed on other modalities. CT can detect early degenerative changes of the facet joints and spondylosis with more accuracy. Bony integrity after fusion is also best assessed by CT.
Disc herniation and associated nerve impingement can be diagnosed by using the criteria developed by Gundry and Heithoff. It is important for the disc protrusion to lie directly over the nerve roots traversing the disc and to be focal and asymmetrical with a dorsolateral position. There should be demonstrable nerve root compression or displacement. Lastly, the nerve distal to the impingement (site of herniation) often enlarges and bulges with resulting edema, prominence of adjacent epidural veins, and inflammatory exudates resulting in blurring the margin.
Lumbar Discography
This procedure is controversial and, whether knowing the site of the pain has any value regarding surgery or not, has not been proven. False positives can occur due to central hyperalgesia in patients with chronic pain (neurophysiologic finding) and due to psychosocial factors. It is questionable to establish exactly when discogenic pain becomes clinically significant. Those who support this investigation advocates strict criteria for selection of the patients and when interpreting results and believe this is the only test that can diagnose discogenic pain. Lumbar discography can be used in several situations, although it is not scientifically established. These include; diagnosis of lateral herniation, diagnosing a symptomatic disc among multiple abnormalities, assessing similar abnormalities seen on CT or MRI, evaluation of the spine after surgery, selection of fusion level, and the suggestive features of discogenic pain existence.
The discography is more concerned about eliciting pathophysiology rather than determining the anatomy of the disc. Therefore, discogenic pain evaluation is the aim of discography. MRI may reveal an abnormally looking disc with no pain, while severe pain may be seen on discography where MRI findings are few. During the injection of normal saline or the contrast material, a spongy endpoint can occur with abnormal discs accepting more amounts of contrast. The contrast material can extend into the nucleus pulposus through tears and fissures in the annulus fibrosus in the abnormal discs. The pressure of this contrast material can provoke pain due to the innervations by recurrent meningeal nerve, mixed spinal nerve, anterior primary rami, and gray rami communicantes supplying the outer annulus fibrosus. Radicular pain can be provoked when the contrast material reaches the site of nerve root impingement by the abnormal disc. However, this discography test has several complications such as nerve root injury, chemical or bacterial diskitis, contrast allergy, and the exacerbation of pain. (Bartynski, Walter S., and A. Orlando Ortiz)
Imaging Modality Combination
In order to evaluate the nerve root compression and cervical stenosis adequately, a combination of imaging methods may be needed.
CT Discography
After performing initial discography, CT discography is performed within 4 hours. It can be used in determining the status of the disc such as herniated, protruded, extruded, contained or sequestered. It can also be used in the spine to differentiate the mass effects of scar tissue or disc material after spinal surgery.
CT Myelography
This test is considered the best method for evaluating nerve root compression. When CT is performed in combination or after myelography, details about bony anatomy different planes can be obtained with relative ease.
When multilevel degenerative disc disease is suspected on an MRI scan, this test can be used to determine the specific nerve root that has been affected. SNRB is both a diagnostic and therapeutic test that can be used for lumbar spinal stenosis. The test creates a demotomal level area of hypoesthesia by injecting an anesthetic and a contrast material under fluoroscopic guidance to the interested nerve root level. There is a correlation between multilevel cervical degenerative disc disease clinical symptoms and findings on MRI and findings of SNRB according to Anderberg et al. There is a 28% correlation with SNRB results and with dermatomal radicular pain and areas of neurologic deficit. Most severe cases of degeneration on MRI are found to be correlated with 60%. Although not used routinely, SNRB is a useful test in evaluating patients before surgery in multilevel degenerative disc disease especially on the spine together with clinical features and findings on MRI. (Narouze, Samer, and Amaresh Vydyanathan)
Electro Myographic Studies
Distal motor and sensory nerve conduction tests, called electromyographic studies, that are normal with abnormal needle exam may reveal nerve compression symptoms that are elicited in the clinical history. Irritated nerve roots can be localized by using injections to anesthetize the affected nerves or pain receptors in the disc space, sacroiliac joint, or the facet joints by discography. (�Journal Of Electromyography & Kinesiology Calendar�)
Laboratory Studies
Laboratory tests are usually done to exclude other differential diagnoses.
As seronegative spondyloarthropathies, such as ankylosing spondylitis, are common causes of back pain, HLA B27 immuno-histocompatibility has to be tested. Estimated 350,000 persons in the US and 600,000 in Europe have been affected by this inflammatory disease of unknown etiology. But HLA B27 is extremely rarely found in African Americans. Other seronegative spondyloarthropathies that can be tested using this gene include psoriatic arthritis, inflammatory bowel disease, and reactive arthritis or Reiter syndrome. Serum immunoglobulin A (IgA) can be increased in some patients.
Tests like the erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) level test for the acute phase reactants seen in inflammatory causes of lower back pain such as osteoarthritis and malignancy. The full blood count is also required, including differential counts to ascertain the disease etiology. Autoimmune diseases are suspected when Rheumatoid factor (RF) and anti-nuclear antibody (ANA) tests become positive. Serum uric acid and synovial fluid analysis for crystals may be needed in rare cases to exclude gout and pyrophosphate dihydrate deposition.
Treatment
There is no definitive treatment method agreed by all physicians regarding the treatment of degenerative disc disease because the cause of the pain can differ in different individuals and so is the severity of pain and the wide variations in clinical presentation. The treatment options can be discussed broadly under; conservative treatment, medical treatment, and surgical treatment.
Conservative Treatment
This treatment method includes exercise therapy with behavioral interventions, physical modalities, injections, back education, and back school methods.
Exercise-Based Therapy with Behavioral Interventions
Depending on the diagnosis of the patient, different types of exercises can be prescribed. It is considered one of the main methods of conservative management to treat chronic low back pain. The exercises can be modified to include stretching exercises, aerobic exercises, and muscle strengthening exercises. One of the major challenges of this therapy includes its inability to assess the efficacy among patients due to wide variations in the exercise regimens, frequency, and intensity. According to studies, most effectiveness for sub-acute low back pain with varying duration of symptoms was obtained by performing graded exercise programs within the occupational setting of the patient. Significant improvements were observed among patients suffering from chronic symptoms with this therapy with regard to functional improvement and pain reduction. Individual therapies designed for each patient under close supervision and compliance of the patient also seems to be the most effective in chronic back pain sufferers. Other conservative approaches can be used in combination to improve this approach. (Hayden, Jill A., et al.)
Aerobic exercises, if performed regularly, can improve endurance. For relieving muscle tension, relaxation methods can be used. Swimming is also considered an exercise for back pain. Floor exercises can include extension exercises, hamstring stretches, low back stretches, double knee to chin stretches, seat lifts, modified sit-ups, abdominal bracing, and mountain and sag exercises.
Physical Modalities
This method includes the use of electrical nerve stimulation, relaxation, ice packs, biofeedback, heating pads, phonophoresis, and iontophoresis.
In this non-invasive method, electrical stimulation is delivered to the skin in order to stimulate the peripheral nerves in the area to relieve the pain to some extent. This method relieves pain immediately following application but its long term effectiveness is doubtful. With some studies, it has been found that there is no significant improvement in pain and functional status when compared with placebo. The devices performing these TENS can be easily accessible from the outpatient department. The only side effect seems to be a mild skin irritation experienced in a third of patients. (Johnson, Mark I)
Back School
This method was introduced with the aim of reducing the pain symptoms and their recurrences. It was first introduced in Sweden and takes into account the posture, ergonomics, appropriate back exercises, and the anatomy of the lumbar region. Patients are taught the correct posture to sit, stand, lift weights, sleep, wash face, and brush teeth avoiding pain. When compared with other treatment modalities, back school therapy has been proven to be effective in both immediate and intermediate periods for improving back pain and functional status.
Patient Education
In this method, the provider instructs the patient on how to manage their back pain symptoms. Normal spinal anatomy and biomechanics involving mechanisms of injury is taught at first. Next, using the spinal models, the degenerative disc disease diagnosis is explained to the patient. For the individual patient, the balanced position is determined and then asked to maintain that position to avoid getting symptoms.
Bio-Psychosocial Approach to Multidisciplinary Back Therapy
Chronic back pain can cause a lot of distress to the patient, leading to psychological disturbances and low mood. This can adversely affect the therapeutic outcomes rendering most treatment strategies futile. Therefore, patients must be educated on learned cognitive strategies called �behavioral� and �bio-psychosocial� strategies to get relief from pain. In addition to treating the biological causes of pain, psychological, and social causes should also be addressed in this method. In order to reduce the patient�s perception of pain and disability, methods like modified expectations, relaxation techniques, control of physiological responses by learned behavior, and reinforcement are used.
Massage Therapy
For chronic low back pain, this therapy seems to be beneficial. Over a 1 year period, massage therapy has been found to be moderately effective for some patients when compared to acupuncture and other relaxation methods. However, it is less efficacious than TENS and exercise therapy although individual patients may prefer one over the other. (Furlan, Andrea D., et al.)
Spinal Manipulation
This therapy involves the manipulation of a joint beyond its normal range of movement, but not exceeding that of the normal anatomical range. This is a manual therapy that involves long lever manipulation with a low velocity. It is thought to improve low back pain through several mechanisms like the release of entrapped nerves, destruction of articular and peri-articular adhesions, and through manipulating segments of the spine that had undergone displacement. It can also reduce the bulging of the disc, relax the hypertonic muscles, stimulate the nociceptive fibers via changing the neurophysiological function and reposition the menisci on the articular surface.
Spinal manipulation is thought to be superior in efficacy when compared to most methods such as TENS, exercise therapy, NSAID drugs, and back school therapy. The currently available research is positive regarding its effectiveness in both the long and short term. It is also very safe to administer under-trained therapists with cases of disc herniation and cauda equina being reported only in lower than 1 in 3.7 million people. (Bronfort, Gert, et al.)
Lumbar Supports
Patients suffering from chronic low back pain due to degenerative processes at multiple levels with several causes may benefit from lumbar support. There is conflicting evidence with regards to its effectiveness with some studies claiming moderate improvement in immediate and long term relief while others suggesting no such improvement when compared to other treatment methods. Lumbar supports can stabilize, correct deformity, reduce mechanical forces, and limit the movements of the spine. It may also act as a placebo and reduce the pain by massaging the affected areas and applying heat.
Lumbar Traction
This method uses a harness attached to the iliac crest and lower rib cage and applies a longitudinal force along the axial spine to relieve chronic low back pain. The level and duration of the force are adjusted according to the patient and it can be measured by using devices both while walking and lying down. Lumbar traction acts by opening the intervertebral disc spaces and by reducing the lumbar lordosis. The symptoms of degenerative disc disease are reduced through this method due to temporary spine realignment and its associated benefits. It relieves nerve compression and mechanical stress, disrupts the adhesions in the facet and annulus, and also nociceptive pain signals. However, there is not much evidence with regard to its effectiveness in reducing back pain or improving daily function. Furthermore, the risks associated with lumbar traction are still under research and some case reports are available where it has caused a nerve impingement, respiratory difficulties, and blood pressure changes due to heavy force and incorrect placement of the harness. (Harte, A et al.)
Medical Treatment
Medical therapy involves drug treatment with muscle relaxants, steroid injections, NSAIDs, opioids, and other analgesics. This is needed, in addition to conservative treatment, in most patients with degenerative disc disease. Pharmacotherapy is aimed to control disability, reduce pain and swelling while improving the quality of life. It is catered according to the individual patient as there is no consensus regarding the treatment.
Muscle Relaxants
Degenerative disc disease may benefit from muscle relaxants by reducing the spasm of muscles and thereby relieving pain. The efficacy of muscle relaxants in improving pain and functional status has been established through several types of research. Benzodiazepine is the most common muscle relaxant currently in use.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
These drugs are commonly used as the first step in disc degenerative disease providing analgesia, as well as anti-inflammatory effects. There is strong evidence that it reduces chronic low back pain. However, its use is limited by gastrointestinal disturbances, like acute gastritis. Selective COX2 inhibitors, like celecoxib, can overcome this problem by only targeting COX2 receptors. Their use is not widely accepted due to its potential side effects in increasing cardiovascular disease with prolonged use.
Opioid Medications
This is a step higher up in the WHO pain ladder. It is reserved for patients suffering from severe pain not responding to NSAIDs and those with unbearable GI disturbances with NSAID therapy. However, the prescription of narcotics for treating back pain varies considerably between clinicians. According to literature, 3 to 66% of patients may be taking some form of the opioid to relieve their back pain. Even though the short term reduction in symptoms is marked, there is a risk of long term narcotic abuse, a high rate of tolerance, and respiratory distress in the older population. Nausea and vomiting are some of the short term side effects encountered. (�Systematic Review: Opioid Treatment For Chronic Back Pain: Prevalence, Efficacy, And Association With Addiction�)
Anti-Depressants
Anti-depressants, in low doses, have analgesic value and may be beneficial in chronic low back pain patients who may present with associated depression symptoms. The pain and suffering may be disrupting the sleep of the patient and reducing the pain threshold. These can be addressed by using anti-depressants in low doses even though there is no evidence that it improves the function.
Injection Therapy
Epidural Steroid Injections
Epidural steroid injections are the most widely used injection type for the treatment of chronic degenerative disc disease and associated radiculopathy. There is a variation between the type of steroid used and its dose. 8- 10 mL of a mixture of methylprednisolone and normal saline is considered an effective and safe dose. The injections can be given through interlaminar, caudal, or trans foramina routes. A needle can be inserted under the guidance of fluoroscopy. First contrast, then local anesthesia and lastly, the steroid is injected into the epidural space at the affected level via this method. The pain relief is achieved due to the combination of effects from both local anesthesia and the steroid. Immediate pain relief can be achieved through the local anesthetic by blocking the pain signal transmission and while also confirming the diagnosis. Inflammation is also reduced due to the action of steroids in blocking pro-inflammatory cascade.
During the recent decade, the use of epidural steroid injection has increased by 121%. However, there is controversy regarding its use due to the variation in response levels and potentially serious adverse effects. Usually, these injections are believed to cause only short term relief of symptoms. Some clinicians may inject 2 to 3 injections within a one-week duration, although the long term results are the same for that of a patient given only a single injection. For a one year period, more than 4 injections shouldn�t be given. For more immediate and effective pain relief, preservative-free morphine can also be added to the injection. Even local anesthetics, like lidocaine and bupivacaine, are added for this purpose. Evidence for long term pain relief is limited. (�A Placebo-Controlled Trial To Evaluate Effectivity Of Pain Relief Using Ketamine With Epidural Steroids For Chronic Low Back Pain�)
There are potential side effects due to this therapy, in addition to its high cost and efficacy concerns. Needles can get misplaced if fluoroscopy is not used in as much as 25% of cases, even with the presence of experienced staff. The epidural placement can be identified by pruritus reliably. Respiratory depression or urinary retention can occur following injection with morphine and so the patient needs to be monitored for 24 hours following the injection.
Facet Injections
These injections are given to facet joints, also called zygapophysial joints, which are situated between two adjacent vertebrae. Anesthesia can be directly injected to the joint space or to the associated medial branch of the dorsal rami, which innervates it. There is evidence that this method improves the functional ability, quality of life, and relieves pain. They are thought to provide both short and long term benefits, although studies have shown both facet injections and epidural steroid injections are similar in efficacy. (Wynne, Kelly A)
SI Joint Injections
This is a diarthrodial synovial joint with nerve supply from both myelinated and non-myelin nerve axons. The injection can effectively treat degenerative disc disease involving sacroiliac joint leading to both long and short term relief from symptoms such as low back pain and referred pain at legs, thigh, and buttocks. The injections can be repeated every 2 to 3 months but should be performed only if clinically necessary. (MAUGARS, Y. et al.)�
Intradiscal Non-Operative Therapies for Discogenic Pain
As described under the investigations, discography can be used both as a diagnostic and therapeutic method. After the diseased disc is identified, several minimally invasive methods can be tried before embarking on surgery. Electrical current and its heat can be used to coagulate the posterior annulus thereby strengthening the collagen fibers, denaturing and destroying inflammatory mediators and nociceptors, and sealing figures. The methods used in this are called intradiscal electrothermal therapy (IDET) or radiofrequency posterior annuloplasty (RPA), in which an electrode is passed to the disc. IDET has moderate evidence in relief of symptoms for disc degenerative disease patients, while RPA has limited support regarding its short term and long term efficacy. Both these procedures can lead to complications such as nerve root injury, catheter malfunction, infection, and post-procedure disc herniation.
Surgical Treatment
Surgical treatment is reserved for patients with failed conservative therapy taking into account the disease severity, age, other comorbidities, socio-economic condition, and the level of outcome expected. It is estimated that around 5% of patients with degenerative disc disease undergo surgery, either for their lumbar disease or cervical disease. (Rydevik, Bj�rn L.)
Lumbar Spine Procedures
Lumbar surgery is indicated in patients with severe pain, with a duration of 6 to 12 months of ineffective drug therapy, who have critical spinal stenosis. The surgery is usually an elective procedure except in the case of cauda equina syndrome. There are two procedure types that aim to involve spinal fusion or decompression or both. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology.�)
Spinal fusion involves stopping movements at a painful vertebral segment in order to reduce the pain by fusing several vertebrae together by using a bone graft. It is considered effective in the long term for patients with degenerative disc disease having spinal malalignment or excessive movement. There are several approaches to fusion surgery. (Gupta, Vijay Kumar, et al)
Lumbar spinal posterolateral guttur fusion
This method involves placing a bone graft in the posterolateral part of the spine. A bone graft can be harvested from the posterior iliac crest. The bones are stripped off from its periosteum for successful grafting. A back brace is needed in the post-operative period and patients may need to stay in the hospital for about 5 to 10 days. Limited motion and cessation of smoking are needed for successful fusion. However, several risks such as non-union, infection, bleeding, and solid union with back pain may occur.
Posterior lumbar interbody fusion
In this method, decompression or diskectomy methods can also be performed via the same approach. The bone grafts are directly applied to the disc space and ligamentum flavum is excised completely. For the degenerative disc disease, interlaminar space is widened additionally by performing a partial medial facetectomy. Back braces are optional with this method. It has several disadvantages when compared to anterior approach such as only small grafts can be inserted, the reduced surface area available for fusion, and difficulty when performing surgery on spinal deformity patients. The major risk involved is non-union.
Anterior lumbar interbody fusion
This procedure is similar to the posterior one except that it is approached through the abdomen instead of the back. It has the advantage of not disrupting the back muscles and the nerve supply. It is contraindicated in patients with osteoporosis and has the risk of bleeding, retrograde ejaculation in men, non-union, and infection.
Transforaminal lumbar interbody fusion
This is a modified version of the posterior approach which is becoming popular. It offers low risk with good exposure and it is shown to have an excellent outcome with a few complications such as CSF leak, transient neurological impairment, and wound infection.
Total Disc Arthroplasty
This is an alternative to disc fusion and it has been used to treat lumbar degenerative disc disease using an artificial disc to replace the affected disc. Total prosthesis or nuclear prosthesis can be used depending on the clinical situation.
Decompression involves removing part of the disc of the vertebral body, which is impinging on a nerve to release that and provide room for its recovery via procedures called diskectomy and laminectomy. The efficacy of the procedure is questionable although it is a commonly performed surgery. Complications are very few with a low chance of recurrence of symptoms with higher patient satisfaction. (Gupta, Vijay Kumar, et al)
Lumbar discectomy
The surgery is performed through a posterior midline approach by dividing the ligamentum flavum. The nerve root that is affected is identified and bulging annulus is cut to release it. Full neurological examination should be performed afterward and patients are usually fit to go home 1 � 5 days later. Low back exercises should be started soon followed by light work and then heavy work at 2 and 12 weeks respectively.
Lumbar laminectomy
This procedure can be performed thorough one level, as well as through multiple levels. Laminectomy should be as short as possible to avoid spinal instability. Patients have marked relief of symptoms and reduction in radiculopathy following the procedure. The risks may include bowel and bladder incontinence, CSF leakage, nerve root damage, and infection.
Cervical Spine Procedures
Cervical degenerative disc disease is indicated for surgery when there is unbearable pain associated with progressive motor and sensory deficits. Surgery has a more than 90% favorable outcome when there is radiographic evidence of nerve root compression. There are several options including anterior cervical diskectomy (ACD), ACD, and fusion (ACDF), ACDF with internal fixation, and posterior foraminotomy. (�Degenerative Disk Disease: Background, Anatomy, Pathophysiology.�)
Cell-Based Therapy
Stem cell transplantation has emerged as a novel therapy for degenerative disc disease with promising results. The introduction of autologous chondrocytes has been found to reduce discogenic pain over a 2 year period. These therapies are currently undergoing human trials. (Jeong, Je Hoon, et al.)
Gene Therapy
Gene transduction in order to halt the disc degenerative process and even inducing disc regeneration is currently under research. For this, beneficial genes have to be identified while demoting the activity of degeneration promoting genes. These novel treatment options give hope for future treatment to be directed at regenerating intervertebral discs. (Nishida, Kotaro, et al.)
Degenerative disc disease is a health issue characterized by chronic back pain due to a damaged intervertebral disc, such as low back pain in the lumbar spine or neck pain in the cervical spine. It is a breakdown of an intervertebral disc of the spine. Several pathological changes can occur in disc degeneration. Various anatomical defects can also occur in the intervertebral disc. Low back pain and neck pain are major epidemiological problems, which are thought to be related to degenerative disc disease. Back pain is the second leading cause of doctor office visits in the United States. It is estimated that about 80% of US adults suffer from low back pain at least once during their lifetime. Therefore, a thorough understanding of degenerative disc disease is needed for managing this common condition. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas*& New Mexico*�
Modic, Michael T., and Jeffrey S. Ross. �Lumbar Degenerative Disk Disease.� Radiology, vol 245, no. 1, 2007, pp. 43-61. Radiological Society Of North America (RSNA), doi:10.1148/radiol.2451051706.
Taher, Fadi et al. �Lumbar Degenerative Disc Disease: Current And Future Concepts Of Diagnosis And Management.� Advances In Orthopedics, vol 2012, 2012, pp. 1-7. Hindawi Limited, doi:10.1155/2012/970752.
Choi, Yong-Soo. �Pathophysiology Of Degenerative Disc Disease.� Asian Spine Journal, vol 3, no. 1, 2009, p. 39. Korean Society Of Spine Surgery (KAMJE), doi:10.4184/asj.2009.3.1.39.
Wheater, Paul R et al. Wheater�s Functional Histology. 5th ed., [New Delhi], Churchill Livingstone, 2007,.
Palmgren, Tove et al. �An Immunohistochemical Study Of Nerve Structures In The Anulus Fibrosus Of Human Normal Lumbar Intervertebral Discs.� Spine, vol 24, no. 20, 1999, p. 2075. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-199910150-00002.
BOGDUK, NIKOLAI et al. �The Innervation Of The Cervical Intervertebral Discs.� Spine, vol 13, no. 1, 1988, pp. 2-8. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-198801000-00002.
Suthar, Pokhraj. �MRI Evaluation Of Lumbar Disc Degenerative Disease.� JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 2015, JCDR Research And Publications, doi:10.7860/jcdr/2015/11927.5761.
Buckwalter, Joseph A. �Aging And Degeneration Of The Human Intervertebral Disc.� Spine, vol 20, no. 11, 1995, pp. 1307-1314. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-199506000-00022.
Roberts, S. et al. �Senescence In Human Intervertebral Discs.� European Spine Journal, vol 15, no. S3, 2006, pp. 312-316. Springer Nature, doi:10.1007/s00586-006-0126-8.
Boyd, Lawrence M. et al. �Early-Onset Degeneration Of The Intervertebral Disc And Vertebral End Plate In Mice Deficient In Type IX Collagen.� Arthritis & Rheumatism, vol 58, no. 1, 2007, pp. 164-171. Wiley-Blackwell, doi:10.1002/art.23231.
Williams, F.M.K., and P.N. Sambrook. �Neck And Back Pain And Intervertebral Disc Degeneration: Role Of Occupational Factors.� Best Practice & Research Clinical Rheumatology, vol 25, no. 1, 2011, pp. 69-79. Elsevier BV, doi:10.1016/j.berh.2011.01.007.
Batti�, Michele C. �Lumbar Disc Degeneration: Epidemiology And Genetics.� The Journal Of Bone And Joint Surgery (American), vol 88, no. suppl_2, 2006, p. 3. Ovid Technologies (Wolters Kluwer Health), doi:10.2106/jbjs.e.01313.
BATTI�, MICHELE C. et al. �1991 Volvo Award In Clinical Sciences.� Spine, vol 16, no. 9, 1991, pp. 1015-1021. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-199109000-00001.
Kauppila, L.I. �Atherosclerosis And Disc Degeneration/Low-Back Pain � A Systematic Review.� Journal Of Vascular Surgery, vol 49, no. 6, 2009, p. 1629. Elsevier BV, doi:10.1016/j.jvs.2009.04.030.
�A Population-Based Study Of Juvenile Disc Degeneration And Its Association With Overweight And Obesity, Low Back Pain, And Diminished Functional Status. Samartzis D, Karppinen J, Mok F, Fong DY, Luk KD, Cheung KM. J Bone Joint Surg Am 2011;93(7):662�70.� The Spine Journal, vol 11, no. 7, 2011, p. 677. Elsevier BV, doi:10.1016/j.spinee.2011.07.008.
Gupta, Vijay Kumar et al. �Lumbar Degenerative Disc Disease: Clinical Presentation And Treatment Approaches.� IOSR Journal Of Dental And Medical Sciences, vol 15, no. 08, 2016, pp. 12-23. IOSR Journals, doi:10.9790/0853-1508051223.
Bhatnagar, Sushma, and Maynak Gupta. �Evidence-Based Clinical Practice Guidelines For Interventional Pain Management In Cancer Pain.� Indian Journal Of Palliative Care, vol 21, no. 2, 2015, p. 137. Medknow, doi:10.4103/0973-1075.156466.
KIRKALDY-WILLIS, W H et al. �Pathology And Pathogenesis Of Lumbar Spondylosis And Stenosis.� Spine, vol 3, no. 4, 1978, pp. 319-328. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-197812000-00004.
KONTTINEN, YRJ� T. et al. �Neuroimmunohistochemical Analysis Of Peridiscal Nociceptive Neural Elements.� Spine, vol 15, no. 5, 1990, pp. 383-386. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-199005000-00008.
Brisby, Helena. �Pathology And Possible Mechanisms Of Nervous System Response To Disc Degeneration.� The Journal Of Bone And Joint Surgery (American), vol 88, no. suppl_2, 2006, p. 68. Ovid Technologies (Wolters Kluwer Health), doi:10.2106/jbjs.e.01282.
Modic, M T et al. �Degenerative Disk Disease: Assessment Of Changes In Vertebral Body Marrow With MR Imaging..� Radiology, vol 166, no. 1, 1988, pp. 193-199. Radiological Society Of North America (RSNA), doi:10.1148/radiology.166.1.3336678.
Pfirrmann, Christian W. A. et al. �Magnetic Resonance Classification Of Lumbar Intervertebral Disc Degeneration.� Spine, vol 26, no. 17, 2001, pp. 1873-1878. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-200109010-00011.
Bartynski, Walter S., and A. Orlando Ortiz. �Interventional Assessment Of The Lumbar Disk: Provocation Lumbar Diskography And Functional Anesthetic Diskography.� Techniques In Vascular And Interventional Radiology, vol 12, no. 1, 2009, pp. 33-43. Elsevier BV, doi:10.1053/j.tvir.2009.06.003.
Narouze, Samer, and Amaresh Vydyanathan. �Ultrasound-Guided Cervical Transforaminal Injection And Selective Nerve Root Block.� Techniques In Regional Anesthesia And Pain Management, vol 13, no. 3, 2009, pp. 137-141. Elsevier BV, doi:10.1053/j.trap.2009.06.016.
�Journal Of Electromyography & Kinesiology Calendar.� Journal Of Electromyography And Kinesiology, vol 4, no. 2, 1994, p. 126. Elsevier BV, doi:10.1016/1050-6411(94)90034-5.
Hayden, Jill A. et al. �Systematic Review: Strategies For Using Exercise Therapy To Improve Outcomes In Chronic Low Back Pain.� Annals Of Internal Medicine, vol 142, no. 9, 2005, p. 776. American College Of Physicians, doi:10.7326/0003-4819-142-9-200505030-00014.
Johnson, Mark I. �Transcutaneous Electrical Nerve Stimulation (TENS) And TENS-Like Devices: Do They Provide Pain Relief?.� Pain Reviews, vol 8, no. 3-4, 2001, pp. 121-158. Portico, doi:10.1191/0968130201pr182ra.
Harte, A et al. �Efficacy Of Lumbar Traction In The Management Of Low Back Pain.� Physiotherapy, vol 88, no. 7, 2002, pp. 433-434. Elsevier BV, doi:10.1016/s0031-9406(05)61278-3.
Bronfort, Gert et al. �Efficacy Of Spinal Manipulation And Mobilization For Low Back Pain And Neck Pain: A Systematic Review And Best Evidence Synthesis.� The Spine Journal, vol 4, no. 3, 2004, pp. 335-356. Elsevier BV, doi:10.1016/j.spinee.2003.06.002.
Furlan, Andrea D. et al. �Massage For Low-Back Pain: A Systematic Review Within The Framework Of The Cochrane Collaboration Back Review Group.� Spine, vol 27, no. 17, 2002, pp. 1896-1910. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-200209010-00017.
�Systematic Review: Opioid Treatment For Chronic Back Pain: Prevalence, Efficacy, And Association With Addiction.� Clinical Governance: An International Journal, vol 12, no. 4, 2007, Emerald, doi:10.1108/cgij.2007.24812dae.007.
�A Placebo Controlled Trial To Evaluate Effectivity Of Pain Relief Using Ketamine With Epidural Steroids For Chronic Low Back Pain.� International Journal Of Science And Research (IJSR), vol 5, no. 2, 2016, pp. 546-548. International Journal Of Science And Research, doi:10.21275/v5i2.nov161215.
Wynne, Kelly A. �Facet Joint Injections In The Management Of Chronic Low Back Pain: A Review.� Pain Reviews, vol 9, no. 2, 2002, pp. 81-86. Portico, doi:10.1191/0968130202pr190ra.
MAUGARS, Y. et al. �ASSESSMENT OF THE EFFICACY OF SACROILIAC CORTICOSTEROID INJECTIONS IN SPONDYLARTHROPATHIES: A DOUBLE-BLIND STUDY.� Rheumatology, vol 35, no. 8, 1996, pp. 767-770. Oxford University Press (OUP), doi:10.1093/rheumatology/35.8.767.
Rydevik, Bj�rn L. �Point Of View: Seven- To 10-Year Outcome Of Decompressive Surgery For Degenerative Lumbar Spinal Stenosis.� Spine, vol 21, no. 1, 1996, p. 98. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/00007632-199601010-00023.
Jeong, Je Hoon et al. �Regeneration Of Intervertebral Discs In A Rat Disc Degeneration Model By Implanted Adipose-Tissue-Derived Stromal Cells.� Acta Neurochirurgica, vol 152, no. 10, 2010, pp. 1771-1777. Springer Nature, doi:10.1007/s00701-010-0698-2.
Nishida, Kotaro et al. �Gene Therapy Approach For Disc Degeneration And Associated Spinal Disorders.� European Spine Journal, vol 17, no. S4, 2008, pp. 459-466. Springer Nature, doi:10.1007/s00586-008-0751-5.
Infections can happen to any individual given specific circumstances, however, infections occurring in HIV/AIDS patients are more commonly referred to opportunistic infections or OIs.
HIV/AIDS severely dampens the immune system of the patient, making it less able to fight off infections. It wipes out the white blood cells that eliminate an infection. Specific types of bacteria, viruses, fungi, and other organisms, which do not commonly result in infections in individuals who are healthy can make those with weak immune system sick. This exposes them to the dangers of suffering from opportunistic infections (OIs). OIs are severe infections that affect an individual due to his or her weak immune system.
The strength of an individual�s immune system with HIV can be estimated through the T cell count, which is also referred to as the CD4 count. When the T cell count is under 200�cells per microL,�it means that the individual condition has deteriorated to AIDS and, thus, he or she faces the risk of suffering from opportunistic infections. Nevertheless, a lot of opportunistic infections can be inhibited when the individual is placed on specific antibiotics and anti-fungal medications. HIV medications can also enhance the T cell count and reduce the risk of the individual suffering from opportunistic infection. This can normally be minimized when the individual is given continual therapy. Opportunistic infections are generally less widespread and less severe in healthy people.
What is an Opportunistic Infection (OI)?
Opportunistic infections (OIs) are the types of infection that commonly develop in individuals with weakened immune systems than in people with healthy immune systems. Individuals with weak immune systems are mostly HIV patients and patients receiving chemotherapy treatments.
OIs are normally caused by a lot of germs which include viruses, bacteria, fungi, and parasites. Germs that cause OIs can be transmitted through various ways including the air, the saliva, semen, blood, urine, poop of an infected person or through contaminated food and water.
Individuals who are more at risk of suffering from OIs are those with their CD4 count below 200, but you can contract some OIs when your CD4 count is less than 500.
OIs are not as widespread now the way they were when HIV and AIDS first originated, due to the fact that a better treatment is now available which minimizes the quantity of HIV in an individual�s body and this increases the immune system. Nevertheless, a number of people with HIV still develop OIs due to the fact that they were unaware that they were infected with the HIV virus for a good number of years after their infection. Individuals who know that they have HIV, but who are not receiving the antiretroviral treatment (ART), will still be infected by OIs. Individuals who have AIDS, but who are not taking medication for the prevention of OIs, can also suffer from OIs.
The best way to stay clear of opportunistic infections is to stay in care and get your�lab tests�carried out. This will help your doctor and other medical teams know when you may be facing the risk of OIs and ensure that they are prevented. Most opportunistic infections can be prevented by taking additional medications.
There are different types of OIs. This includes the following amongst others:
Bacterial infections like�tuberculosis�and similar disease,�Mycobacterium avium complex�(MAC)
Viral infections like�cytomegalovirus�(CMV) and�hepatitis C
Fungal infections such as yeast infections, cryptococcal meningitis,�pneumocystis carinii pneumonia(PCP) and�histoplasmosis
Parasitic infections like crypto (cryptosporidiosis) and toxo (toxoplasmosis)
Having HIV/AIDS and complications from common illnesses like flu.
Salmonella�infection
Herpes simplex virus 1 (HSV-1) infection. This is a viral infection that can result in a sore mouth and face
Salmonella�infection a bacterial infection that affects the gut.
Candidiasis (or thrush). This is a fungal infection of the mouth, esophagus, or vagina
Toxoplasmosis (TB). This is a parasitic infection that can have a harmful effect on the brain.
You can avoid being infected by taking medication for your HIV/AIDS. Taking HIV medications prevents HIV from injuring and weakening your immune system. Due to the fact that HIV medicines are now extensively used in the United States, the number of people who develop OIs has drastically reduced. You can also limit your exposure to causative factors by engaging in safe sex, washing your hands thoroughly and frequently, and cooking your foods properly.
Why Do HIV/AIDS Patients Get OIs?
As soon as an individual is infected with HIV, the virus starts to multiply and begins to injure the individual�s immune system and immune function. A weak immune system makes it difficult for an individual�s body to ward off HIV-related OIs.
HIV medication inhibits the capacity of HIV to cause damage to the immune system. However, if the individual does not take the medication, HIV will gradually be destroyed by the immune system. Most OIs, for instance, the ones that contain specific forms of pneumonia and tuberculosis (TB), are taken as AIDS-defining conditions. AIDS-defining conditions are infections and cancers that are life-threatening in individuals suffering from HIV.
Prevalence of OIs in People with HIV/AIDS
OIs were formally the leading cause of death among individuals with HIV before the advent of medications used in the treatment of HIV infection. Now that HIV medicines are very widespread in the US, the occurrence of OIs among aids patients has been reduced. HIV medications reduce the ability of HIV to damage the immune system and by so doing, it impedes the occurrence of OIs.
Prevention of Opportunistic Infections
The best ways to prevent yourself from becoming infected with an OI are to start medical care and to take HIV medications according to the doctor�s prescription. Sometimes, your doctor will also recommend drugs specifically for the prevention of specific types of OIs. When you take your HIV drug, you can reduce the amount of HIV in your body and this would, in turn, increase your immune health and prevent you from being infected by OIs.
It is particularly significant that you go through standard check-ups. While you go, remember to go with all your medications and take the drugs according to the recommended dosage and time. You may have to take HIV medications for the length of your life. Other things you can also do to improve your immune function and minimize opportunistic infections include the following:
Use condoms every time you have sex and in the correct manner to limit your exposure to sexually transmitted infections.
Don�t share tools for drug injection with anyone. Blood infected with hepatitis C can stay in syringes and needles after they are used and the infection can be transferred from one user to another user.
You need to get vaccinated with a suitable vaccine. Your medical teams will advise you on the best vaccine to take.
Limit your contact with germs that cause OIs. For instance, germs that cause tuberculosis are found in the poops, saliva, or on the skin of animals.
Be cautious with things you eat and drink. Avoid eating undercooked eggs, unpasteurized (raw) milk and cheeses, unpasteurized fruit juices, or raw seed sprouts. Avoid drinking water that is not treated, like water from lakes or rivers. Depending on your country, tap water is also not safe for drinking. Make use of bottled water or water filters.
If you are visiting abroad ensure that the food and water you eat and drink will not make you sick.
Find out from your doctor other safety precautions you need to take at work, at home, and while on a holiday trip to ensure you stay safe.
Treatment of Opportunistic Infections
There are various medications to treat HIV-related OIs. These include antiviral,�antibiotic, and�anti-fungal�medication. The type of drug you will need to take depends on the particular OI.
As soon as the OI is effectively treated, an individual may continue to use the same medication or extra medication to inhibit the reoccurrence of OIs. An OI can be a severe medical condition that may be difficult to treat. The development of an OI possibly implies you have a weak immune system and that you are not putting your HIV properly in check. This is why it is essential to take your medication according to the prescription and book appointments with your doctor for routine checks to minimize the spread of the virus. This also ensures that you keep your immune system healthy.
Understanding Common Opportunistic Infections
HIV and Rheumatic Disease
Rheumatic diseases that are linked with HIV affect individuals of all age groups. However, they are more common among individuals between twenty to forty years of age. An individual may contract HIV-related rheumatic diseases before being infected with HIV. The signs and symptoms of rheumatic diseases, their treatment, and HIV infection can all have common characteristics. The majority of people with HIV-related rheumatic diseases get better after several HIV treatments.
Several older medications for HIV and AIDS can cause joint and soft tissue ache and muscle weakness. Others are associated with metabolic bone disease. Many people with HIV experience musculoskeletal issues with pain affecting the joints, muscles, and bones. HIV infection can result in rheumatic (joint and muscle) which can include joint pain, arthritis, muscle pain, weak spot, and exhaustion.
However, it is not every muscle, bone, and joint complaint experienced by people who have HIV come from HIV. Some of them occur due to other reasons. It can also come with supplementary articular symptoms, like uveitis or eye inflammation, which may also exist in individuals with HIV who are suffering from arthritis. Occasionally, the individual starts to experience these symptoms before observing the HIV signs.
HIV-associated rheumatic diseases are diseases of the joints and muscles that affect an individual with HIV infection. It can result in aching and inflammation. Pain in the joints, soft tissues, adjoining joints, and muscles are frequently the foremost symptoms experienced by 5% of HIV positive patients.
Less widespread rheumatic diseases that can be experienced by individuals suffering from HIV are:
Infection of the joints also known as septic arthritis, muscles infections known as myositis and infection of the bones known as osteomyelitis.
Psoriatic arthritis
Reactive arthritis
Polymyositis or irritation of muscles
Fibromyalgia
Vasculitis or swelling of blood vessels
Individuals with HIV may experience joint, soft tissue, muscle, or bone issues from the medication they are taking for the management of HIV. These include things like gouty arthritis, tenosynovitis, inflammatory myopathy or muscle disease, osteonecrosis, osteoporosis, and lipodystrophy or atypical fat circulation. Nearly all the issues are connected with taking drugs that are no longer prescribed as the first set of treatments by experts. It is progressively more uncommon to experience these types of side effects with the drugs that are presently prescribed by the US Department of Health and Human Services.
Even when the proper medication is used, the individual may experience Immune reconstitution inflammatory syndrome. As the CD4 T cells start to recuperate their number and function, individuals infected with HIV may experience overpowering systemic inflammatory reactions together with fever, malaise, and deterioration of formerly affected organ systems.
Causes of HIV-Associated Rheumatic Diseases
HIV-related rheumatic illnesses can be experienced by both males and females, irrespective of their ages and their ethnic background. Widespread risk factors of HIV infection include unprotected sex and the administration of IV intravenous medication with shared needles. There are many reasons why individuals with HIV experience rheumatic disease. The infection can be due to direct cause, while some can also be caused by other viruses or bacteria.
Diagnosis and Treatment of HIV-Related Rheumatic Diseases
HIV-related rheumatic diseases can be treated with the use of antiretroviral drugs. The combination antiretroviral therapy (cART) use started in the mid-1990s. cART is frequently referred to as the �cocktail� of HIV medications due to the fact that it is the unification of up to three HIV medications. This treatment has tremendously increased the symptoms of HIV, in addition to the ones that affect the joints and the muscles.
the cART has minimized the number of HIV patients that suffer from a rheumatic disease. And when they do get one, it is much easier to treat. The majorities of HIV patients respond very well to regular treatments. This is a combination of pain relief medications and anti-inflammatory medicines given to reduce inflammation, aching, and fever.
Individuals who respond poorly are prescribed medications that repress their immune system. They may also require physical therapy to alleviate symptoms, avoid deforming their joints, and improve their function.
How to Prevent HIV-Related Rheumatic Diseases
Most factors that increase your risk of suffering from HIV also increase your risk for HIV-related rheumatic disease. To minimize your risk of suffering from the two diseases, you should engage in safe sexual practices. If you are HIV infected, you need to take your medication as the doctor prescribed. Again, the Centers for Disease Control and Prevention recommend that individuals with HIV go for HIV routine screening in all healthcare settings for individuals between the age of thirteen and sixty-four years old. Specific groups ought to be more concentrated upon such as seniors with an active sex life together, pregnant women that are mostly less than 24 years, and men who engage in sexual activities with fellow men.
How to Manage HIV & Rheumatic Diseases
Individuals with HIV who have money to pay for cART and whose body can tolerate them commonly live longer. Nevertheless, HIV-related rheumatic disease can result in uneasiness, weakness of the muscle, and impaired function. To stay healthy as an HIV patient apart from taking your medication as prescribed, you must also eat a balanced diet and engage in proper exercise. If you experience weak joints or pain or weakness of the muscles while you take HIV drugs, take the medication to your doctor, and have a thorough review of the medications you are taking. Find out if any of the symptoms you are experiencing is a result of the medication you are taking.
Toxoplasmosis in HIV-Infected Patients
Toxoplasmosis is an infection that is experienced by people all over the world. It is usually caused by a Toxoplasma parasite that infests the individual without resulting in any serious symptoms. Nevertheless, the parasite sticks with the individual�s body and can result in a severe brain infection among people suffering from HIV/AIDS.
Individuals that are diagnosed with HIV are usually recommended to go for a blood test to check if they have been infected by the Toxoplasma parasite before that time.
Toxoplasmosis is the most widespread central nervous system infection experienced by people diagnosed with the acquired immunodeficiency syndrome (AIDS), especially those of them that are not being given suitable prophylaxis. The Toxoplasmosis infection is spread all over the globe and transmitted by the intracellular protozoan parasite known as�Toxoplasma gondii. Individuals with a healthy immune system that are suffering from standard toxoplasmosis are normally asymptomatic and dormant infection can stick with the individual all through his or her life. However, in individuals with a weak immune system, particularly people suffering from AIDS, the parasite can become activated again and result in disease, especially when his or her CD4 count measures lower than 100�cells per microL.
Epidemiology
If the T count of a patient with AIDS is below 100�cells per microL, the individual is recommended to take preventive treatment. There are some antibiotics used to prevent PCP. These antibiotics can also be used to prevent Toxoplasma. The likelihood of reactivated toxoplasmosis emerging among AIDS patients who have a CD4 count less than 100�cells per microL, who are toxoplasma seropositive and are not being given efficient prophylaxis or antiretroviral therapy is as large as 30%. This reactivation normally takes place in the central nervous system (CNS).�
Transmission
Human beings normally get the infection by eating infectious oocysts, normally from soil or cat litter infected with catlike poops, or non-properly cooked meat from an animal that is infected. If an individual swallows�T. gondii oocysts, the parasite raids the intestinal epithelium and circulate all through the body. Afterward, they encyst into any form of composite cell and remain inactive inside the tissues of the individual all through the person�s life.
How Common is the Infection?
The spread of the infection caused by�T. gondii differs greatly across different countries of the world and the range differs roughly by 11% in the United States to over 80% in some European, Latin American, and African nations. Generally, the seroprevalence of antibodies to�T. gondii�amongst HIV-infected individuals is similar to the rate of seropositivity in the general population and is not related to possessing a cat. Nevertheless, the prevalence may be associated with age. For instance, a research study with HIV-infected women in the United States found that individuals 50 years old or younger are probably going to be more seropositive compared to younger women.
Blood Test and Prevention
If the result of the blood test indicates that the individual has not previously contracted the toxoplasmosis infection, it is very essential for the individual to stay away from such environment that would expose him or her to the infection.
Causes and Sources
The widespread sources of the parasite are raw or uncommon meats like lamb, beef, pork, or venison meats; cat stool, and soil.
Prevention
The preventive methods an individual infected with HIV, who have not been exposed to Toxoplasma in the past, include the following:
Avoid eating raw or uncommon lamb, beef, pork, or venison. Meat that is pink in color shows that it is not properly cooked. The interior temperature of the meat must be up to 165�F and above.
Do not change your cats litter by yourself. If no one is around to assist you, make use of hand gloves and wash your hands properly afterward to ensure that they don�t touch your hands. Also, try to avoid touching wandering cats.
Wash hands after farming.
Always wash your hands and cooking worktops after preparing raw meat or poultry.
Always wash your fruits and vegetables thoroughly if you want to eat them raw.
HIV and Hepatitis B
Hepatitis B is a liver disease that is caused by a virus known as Hepatitis B virus (HBV). When an individual is infected with both HIV and HBV, it is referred to as HIV/HBV coinfection. Individuals with HIV/HBV coinfection ought to be treated for the two-health condition. The abbreviation HBV can be used to represent the virus or the disease itself.
HBV can either be a quick-fix or acute condition or a long-term illness which can be chronic.
Acute HBV condition can exist for less than six months after an individual is exposed to HBV. Acute HBV can deteriorate to chronic HBV, although this is not always the case.
Chronic HBV is a lifelong disease. Without treatment, chronic HBV can cause liver cancer or liver damage that leads to liver failure. HBV is a contagious disease that can spread from person to person.
Transmission of HBV
HBV is transmitted through contact with the blood, semen, or other body fluid of an individual who has HBV. In the US, HBV is most commonly dispersed through sexual activities.
HBV can also be dispersed through the following methods:
By using the needle or other tools used for drug injection which has been used for an individual with HBV
By using razors, toothbrushes, or related materials that has been used by an infected person.
From an unintended puncture or cut from an HBV-infected needle or other pointed materials
Congenitally through a mother to her baby during childbirth
Connection Between HIV and HBV
HIV and HBV both can be dispersed through the following ways: semen, blood, or other body fluids of an infected person. Thus, the key risk factors for HIV and HBV are equivalent: having unprotected sex and medical treatments that involve the use injection medicines.
It was found by the�Center for Disease Control and Prevention (CDC) that roughly 10% of individuals with HIV in the United States also suffer from HBV. Infection with both HIV and HBV is known as HIV/HBV coinfection. Chronic HBV worsens faster and easily deteriorates to cirrhosis, which is the final stage of liver disease and liver cancer in individuals suffering from a combination of HIV and HBV coinfection. However, chronic HBV doesn�t seem to cause HIV to increase faster in individuals with HIV/HBV coinfection.
Prevention of HBV Infection
The best prevention method for HBV infection is through the�hepatitis B vaccine.
CDC recommends that individuals with HIV, and those at risk for HIV, get the HBV vaccine or the combination of the two hepatitis A virus [HAV]/HBV vaccine. The housemates and sexual partners of individuals living with HBV need to also be vaccinated. HIV patients can also prevent infection from HBV through the following:
Make use of condoms during sex to lesson HBV infection risk and risk with other sexually transmitted diseases like�gonorrhea�and�syphilis.
Avoid using injections. However, if you must, avoid sharing needles, syringes, or other tools use in injecting medications.
Don�t share toothbrushes, razors, or other personal materials that may be infected by the blood of the person suffering from HB.
If you are getting a tattoo or body piercing, ensure the instruments you are using are sterile.
Why People with HIV Must be Tested for HBV
All people infected with HIV ought to be tested for HBV. Testing for HIV can discover HBV infection even when an individual has no symptoms of the disease.
There are many forms of blood tests that can be conducted for HBV. The outcome of the different tests has a different significance. For instance, a positive hepatitis B surface antigen (HBsAg) test outcome is used to indicate that an individual has acute or chronic HBV and can transfer the virus to others.
Why HBV Therapy is Essential for HBV/HIV Coinfected Patients
Liver disease may deteriorate faster in individuals co-infected with HBV/HIV and could result in severe liver disease impediments like cirrhosis and liver cancer at early ages.
Once HIV patients co-infected with HBV start to take antiretroviral therapy their risk of developing hepatotoxicity is increased more than in individuals who only have HIV alone.
Hepatitis B in HIV-infected patients has a close link with a lower CD4 T-cell count than HIV-monoinfected individuals.
It has not yet been discovered scientifically whether hepatitis B results in an increase of the HIV disease or if hepatitis B changes the response of HIV patients to antiretroviral therapy (ART). Nonetheless, when the individual starts the ART therapy, he or she could face the risk associated with a higher risk of liver inflammation in coinfected individuals, which usually results in ALT (Alanine Aminotransferase) flickers or an increase in liver enzymes. This may reproduce both an immune response against hepatitis B and/or drug toxicity.
Symptoms of HBV Infection
Many people with acute HBV don�t experience symptoms of infection. A number of people can exhibit symptoms of HBV immediately after they have been infected. Mild to serious symptoms of acute HBV are listed below:
Appetite loss
Weariness
Nausea
Fever
Stomach ache
Dark urine
Clay-colored poop
Joint and tummy pain
Jaundice or yellow color of the skin and whitening of the eyes.
A number of people with chronic HBV don�t exhibit symptoms for a number of years. Abnormal�liver function tests�may be the first indication of chronic HBV infection.
Treatment for HBV
Commonly, HBV is treated with antiviral drugs. The medication helps to slow down or inhibit HBV from injuring the liver. People with HIV/HBV coinfection ought to be treated for the two infections. A number of HIV medications are effective for the treatment of both HIV�and�HBV.
The choices of medications to treat HIV/HBV coinfection vary depending on the individual. For instance, a number of people may take just medications that are also efficient against HBV. Other individuals may take HIV drugs and an HBV antiviral medicine. If you have HIV/HBV coinfection, speak with your health care provider to discover which medication is the best for you.
HIV and Hepatitis C Infection
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). HCV is a communicable disease that can be transferred from one individual and another. HCV is mainly dispersed from one individual to the other through contact with infected blood. The majority of people with HCV get the infection by sharing needles or other tools for injecting drugs. The abbreviation HCV can be used for representing the virus or the disease that results from it. HCV can be acute type which lasts short-term or a long-term or chronic illness:
Acute HCV manifests within six months after an individual contracts HCV. In most people, acute HCV becomes chronic HCV.
Chronic HCV can last for a long time. If the individual does not receive treatment, the chronic HCV can result to liver cancer or serious liver damage that can result to liver failure.
Mode of Transmission
HCV can be transferred from one individual to the other, mainly through blood contact of an individual who is infected with HCV. In the United States, HCV is mostly dispersed by sharing needles or other injection drug equipment with an individual who has been infected by HCV.
Connection Between HIV and HCV
HIV and HCV infection can both be dispersed through the blood. Two of them also have as their risk factor the use of injection drugs. Sharing needles or other drug-injection equipment increase the risk of contracting HIV or HCV from any blood that has been previously infected. The Centers for Disease Control and Prevention (CDC) data specified that roughly 25% of individuals with HIV in the United States also suffer from HCV. It also states that roughly 50 � 90% of individuals who make use of injections suffer from HCV. When an individual is infected with both conditions, it is referred to as HIV/HCV coinfection.
In individuals with HIV/HCV coinfection, HIV may make severe HCV to progress quicker. It is not yet known if HCV increases the worsening effects of HIV.
Prevention of HCV
The most appropriate way to protect an individual against HCV is not through drug injections. If you are injecting drugs, it is better to make use of fresh and sterile needles. Avoid making use of needles previously used or sharing needles, syringes, or other equipment for injecting drugs.
Other things individuals with HIV can do to protect themself from HCV infection are:
Avoid sharing toothbrushes, razors, or other personal items that may be infected by the blood of a sufferer.
If you have a tattoo or body piercing, ensure the instruments used are germ-free.
During sex, make use of condoms. Although it can be contacted through sexual contacts, the risk of HCV through this form is usually minimal. However, the risk increases if an individual is HIV positive.
Condoms also minimize the risk of�HIV transmission�and infection with other sexually transmitted diseases like�gonorrhea and�syphilis.
People with HIV and Test for HCV
All individuals with HIV need to undergo tests for HCV. Normally, an individual goes through an HCV antibody test as the first line of treatment. This test is carried out to examine if the antibodies of HCV are present in the blood. HCV antibodies are disease-fighting proteins that the body produces in response to HCV infection. If an individual shows a positive result on an HCV antibody test, it implies that the individual has been uncovered to HCV at a point in their life.
When the result of the test reads positive, it must be confirmed by a second test. The second test is carried out to verify if HCV is present in the blood of the individual. If the result is positive, it means the individual is suffering from HCV.
Symptoms of HCV infection
Many people who have acute HCV don�t experience symptoms. But a number of people can have signs of HCV shortly after becoming infected. Gentle to a more serious symptom of acute HCV can include the following:
Fever
Exhaustion
Loss of appetite
Feeling sick
Vomiting
Stomach ache
Dark-colored urine
Clay-colored bowel movements
Joint pain
Jaundice or yellowish skin or whitening of the eyes
The majority of patients suffering from chronic HCV have no visible signs. Chronic HCV is frequently discovered by conducting a standard�test for liver function.
Treatment for HCV
HCV is treated with antiviral medications. The drug is very effective for slowing down or stopping HCV from injuring the liver. A number of recent medications for the treatment of hepatitis C are more efficient. They come with fewer side effects than older medications. The newer HCV medicines may get rid of HCV from the body of the individual entirely.
Individuals with HIV and HCV coinfection are treated for the infections concurrently. The commencement of the treatment and the medication to use depend on the individual. This is essential because a number of HIV and HCV medications may affect the health if used together. It is better to speak with your doctor for advice if you have HIV/HCV coinfection.
Taking HIV and HCV drugs concurrently may increase the risk of drug-drug interactions and side effects. Health care providers recommend HIV and HCV medicines cautiously to avoid�drug-drug interactions�and strongly monitor those receiving the medications for any side effects.
�
Histoplasmosis
Histoplasmosis is a disease caused by a fungus or mold known as Histoplasma. The infection is transmitted to an individual when he or she breathes the fungal spores. It cannot be transferred from an individual to individual through physical contact.
The fungus usually grows in soil and places that are contaminated with bat or bird droppings. It is frequently seen in places like Mississippi, Ohio, and St. Lawrence River valleys, the Caribbean, southern Mexico, and some parts of Central and South America, Africa, and Asia. It can result in pneumonia in individuals who are diagnosed with HIV, especially those with a low T cell count, and who resides in places with a high risk of infection.
Individuals who are visiting or living in these places must avoid engaging in activities that place them on a high risk of suffering from the condition like digging up of soil under bird roosting sites, knocking down of old buildings or investigating caves.
An anti-fungal treatment may be prescribed for individuals that have a low T cell count usually less than 150�cells per microL�who are at high risk of being infected; this includes individual living in the locations where the infections are frequently found.
Histoplasmosis is not commonly serious and doesn�t come with symptoms. If you ever get sick, it normally affects your lungs. Symptoms of Histoplasmosis are nausea, feverishness, chest aches, and a dry cough. In serious instances, histoplasmosis can disperse to other organs of the body. When this happens, it is referred to as disseminated disease. This frequently occurs in newborns, young children, seniors, and individuals who have problems with their immune system and immune function.
Your doctor may conduct a lot of tests to make the diagnosis. These are chest x-rays, CT scan of the lungs, or examination of blood, urine, or tissues for symptoms of the fungus. Mild instances of the infection are usually reduced after sometimes without any form of treatment. However, chronic or more serious cases are managed with the use of anti-fungal medications.
Test and Diagnoses
Fungal tests are normally used to diagnose a fungal infection for proper guidance on the treatment of the condition and to examine how effective the medications used are. A number of less serious skin and yeast infections would require a clinical examination of the body parts that are affected. This can suitably be carried out through a microscopic examination of the sample. It is sufficient to discover the presence of fungus and not a specific type of fungus. The medical team can make use of a number of topical and oral anti-fungal drugs and medications.
To get persistent, deeper, or�systemic�infections, a lot of tests may be carried out. To discover the type of fungus that is present, fungal cultures are normally utilized.
Most fungi grow slowly. Tests, thus, usually take weeks to produce results. Susceptibility testing�is normally carried out on fungi isolated from a culture. This can be used to determine the anti-fungal drug, which can work best from the treatment of the condition.
Tests for fungal�antigens and�antibodies�may be prescribed to check if an individual has, or recently had, a particular type of fungal infection. They are faster than fungal cultures. However, they are used to test for particular species of specific fungus. Therefore, your medical team must be aware of the type of fungus to test for.
Most people who have the infection also suffered from fungal antibodies in the past from a previous exposure to the organism, thus one antibody test may not be sufficient to verify if the infection is present in the present situation. Often times, blood samples are taken two to three weeks difference for acute�and�convalescent results. The test is usually conducted to show if antibody levels (titers) are altering. The evaluation of these results may take quite a few weeks.
Molecular tests can also be used to determine the fungi that have grown in culture. It can occasionally be used to discover particular fungus present in the sample immediately.
Who is at Risk for Histoplasmosis?
Histoplasmosis can be contracted by any individual who lives in a high-risk zone or an area where Histoplasma�lives in the environment. Histoplasmosis is frequently connected with activities that upset soil, especially soil that is made up of bird or bat droppings. Specific groups of individuals face a greater risk of developing more serious types of Histoplasma. This includes individuals with weak immune systems like people who:
Have HIV/AIDS
Did organ transplanting
Are on medications like corticosteroids or TNF-inhibitors
Are Infant
Are Seniors 55 years old and more
Prevention of Histoplasmosis
Because the disease is transferred through inhalation of the causative organism, it is very difficult for the individual to avoid contracting the disease if one is living in locations that are highly exposed to these factors.
If you are living in areas that have a greater risk to the infection, you must try to avoid engaging in activities that are linked with the spread of the condition like cleaning chicken coops and similar activities. You should get professional cleaners who specialize in the removal of dangerous waste to help you clean huge amounts of bird or bat droppings.
Treatment for Histoplasmosis
Most infected people would require anti-fungal treatment for histoplasmosis.
Your doctor may conduct a lot of tests to make the diagnosis. These are chest x-ray, CT scan of the lungs, or examination of blood, urine, or tissues for symptoms of the fungus. Mild instances of the infection are usually reduced, sometimes without any form of treatment. However, chronic or more serious cases are managed with the use of anti-fungal medications.
Cytomegalovirus (CMV)
Cytomegalovirus (CMV) is a widespread virus that infects a lot of people no matter their age. Roughly one in three children in the US are already infected with CMV before they are five years old. More than half of the adults who are forty years old have already contracted CMV infection. As soon as CMV is found on the body of an individual, it stays there all throughout their life and can reactivate it. An individual can also be re-infected with another type of virus or strain. Commonly, a number of adults with CMV are usually diagnosed by the time they get to forty years of age. Cytomegalovirus (CMV) is a virus that mostly infects people all over the world. CMV can result in a calm illness with fever and body aches, but sometimes, those infected may not experience any symptom.
CMV can stay in the body of AIDS patient and cause sickness in the eyes, digestive system, brain, and spinal cord. The most widespread CMV infection is eye or retina infection. It can create a blurring effect and lead to increasing loss of vision in patients with AIDS. If the blood test of a person with HIV has a sign of previous infection, you need to do a routine eye examination of your retina if your T cell counts are less than 250�cells per microL,�whether or not they have any eye symptoms.
CMV, apart from causing problems for people with weak immune systems, can also cause problems for a child in the womb if the mother is infected with the virus when she is pregnant. The majority of people infected by the viral condition do not have any visible signs. This is due to the fact that the healthy immune system normally prevents the carrier of the virus from making him or her sick. Nevertheless, CMV infection can result in severe health issues in individuals who have weakened immune systems. It also severely affects kids infected while they were in the womb.
Signs and Symptoms
Many people who are infected with CMV have no symptoms and aren�t aware that they have been infected. In some instances, healthy people who are infected may suffer from mild illness which can include:
Fever
Painful throat
Exhaustion
Inflamed glands.
Swollen lymph�nodes
Headache
Exhaustion
Lethargy
Muscle pains
Appetite loss
Babies born with CMV in the womb are usually born very sick at the delivery time. Some of the symptoms shown by babies when they are born are:
Jaundice or yellow skin color
Low birth weight
Seizures
Inflamed spleen
Inflamed liver
Pneumonia, pneumonitis or the swelling of the respiratory tract
Individuals that are receiving immunosuppressant medicines for conditions, such as human immunodeficiency virus (HIV) or from an�organ�transplant, may experience serious symptoms. Immunosuppressant medicines reduce or restrain the immune system. Symptoms of serious CMV are:
Blindness
Swelling of the respiratory tract
Diarrhea
Esophagus�or intestines bleeding�ulcers
Seizures
On rare occasions, CMV can result in mononucleosis, hepatitis or liver issues in healthy individuals. However, people with weak immune systems who are infected with CMV can experience more serious symptoms affecting their eyes, lungs, liver, esophagus, stomach, and intestines. Babies born with CMV can have brain, liver, spleen, lung, and growth issues. Children born with congenital CMV infection commonly have hearing issues. Some are discovered immediately, while others are not discovered until late into their childhood.
Transmission and Prevention
The body fluids of individuals with CMV may contain CMV virus. It can be found in their body fluids like urine, saliva, blood, tears, semen, and breast milk. You can get CMV from an individual who is infected through the following manners:
Through direct contact with the urine or saliva of the infected individual, especially when it is from babies and young children
Through sexual contact
Through the breast milk
From organs infected by the virus. It can also be contacted through infected blood during blood transfusions
It can be transferred from mother to child during pregnancy (congenital CMV)
Standard hand washing, especially after changing diapers, is highly essential to ensure you minimize the dissemination of the infection, and may lessen exposures to CMV.
Diagnosis of CMV
CMV infections are normally diagnosed via blood tests
How CMV is Treated
Healthy individuals who caught CMV infections normally do not need any medical treatment. Medications can treat CMV infection in individuals with weak immune systems and in infants with�congenital CMV infection. Regular antibiotics cannot treat CMV. It is usually managed with antiviral drugs. Antiviral drugs slow down the virus activities but do not cure it.
Treatment to prevent infection with CMV is not generally recommended as it doesn�t help survival. Nevertheless, an individual with early symptoms of CMV retinitis like blurry vision, blind spots, flashing lights, or floaters must contact their healthcare provider as soon as possible because this treatment is efficient if treated as soon as they manifest.
What Causes Cytomegalovirus?
The virus that causes cytomegalovirus is related to the viruses that cause chickenpox and mononucleosis. The germs find their way into body fluids, like saliva, blood, urine, semen, and breast milk. An individual can transfer the virus to others when it is active in his or her system. It is normally transmitted from one person to the other through sexual contact or contact with the blood and other fluids in the body. CMV can seldom be transferred through the processes of blood transfusion or organ transplantation.
An infection of CMV in a pregnant woman can cause a miscarriage, giving birth to a dead child or death of the newborn. Newborns who survive are at an increased risk for hearing loss and mental disability. However, only a small percentage of newborns infected with CMV during pregnancy experience problems from the virus. Most are born healthy or with only mild CMV symptoms.
If you are pregnant and your baby has CMV, your doctor will likely check your baby for any health problems once he or she is born so they can be treated early. Treatable symptoms in newborns include pneumonia, hearing loss, and�inflammation�of the eye.
Mycobacterium Avium Complex (MAC)
Mycobacterium Avium Complex (MAC) is a severe sickness caused by common bacteria. MAC is also referred to as MAI (Mycobacterium Avium Intracellulare). MAC infection can be situated only on a single part of your body or scattered all over the body during, which it is occasionally referred to as DMAC. MAC infection frequently happens in the lungs, intestines, bone marrow, liver, and spleen.
The bacteria that cause MAC are extremely widespread. They are located in water, soil, dust, and food. It is roughly prevalent in the body of every individual. The body of an individual with a healthy immune system will fight against MAC. However, individuals who have a weak immune system can easily suffer from MAC disease. Roughly half of the individuals who have AIDS are likely to suffer from MAC, particularly if their�CD4 cell count�is not up to 50 per microL. MAC nearly never results in sickness in individuals with over 100 CD4 cells.
Mycobacterium avium complex (MAC) can make the individual start to experience high fevers, abdominal pain, and weight loss. Mycobacterium avium can be found all through the environment; you can hardly protect yourself from being infected by taking personal protective measures. Nevertheless, an antibiotic can be given to the individual to help prevent infection from the virus. HIV patients with the T cell count less than 50 cells per microL are commonly recommended to take the antibiotics. They�d continue the treatment until their T cell count goes higher than 100 cells per microL within a span of at least three months.
Mycobacterium avium�complex (MAC) infection can be caused by one of two nontuberculous mycobacterial species which can be�M. aviumor�M. intracellulare. These organisms can infect individuals suffering from HIV infection or an individual who is not HIV positive. The two major forms of MAC infection in individuals with HIV are disseminated disease and focal lymphadenitis. As opposed to these rare pulmonary infection is commonly witnessed in immune-competent patients.
Among people infected with HIV, MAC infection is most commonly witnessed in individuals with a CD4 count less than 50 cells per microL. It was found that there is a remarkable reduction in the number of new cases of MAC infection due to the treatment with the use of prophylaxis to treat MAC infection than when the epidemic originally appeared. This is even additionally reduced with the introduction of efficient antiretroviral therapy and broad use.
Dramatic declines in the rate of new MAC cases accompanied the use of prophylaxis against MAC infection early in the epidemic and more recently, the widespread use of effective antiretroviral therapy.
How MAC is Transmitted
The method of infection for�Mycobacterium avium�complex (MAC) is through breathing or ingestion. MAC causative organisms are everywhere in the environment. They can also be found in the water and soil.
There is no requirement for individuals hospitalized with MAC infection to be isolated given that individual-to-individual or common source spread of the disease is uncommon. In one study that involves 32 individuals with AIDS and MAC from a daycare center in France that lasted for more than a thirteen-month period, the strains of organisms were varied by pulsed-field gel electrophoresis. The second series of 130 isolates from children, both infected with HIV and those not infected, also did not exhibit a clonal origin for the strains, even though HIV-infected children were frequently infected more than the controls.
Diagnoses of MAC
MAC symptoms include high fevers, colds,�diarrhea, weight reduction, tummy ache, fatigue, and�anemia. When MAC spreads in the body, it can result in blood infections, hepatitis, pneumonia, and other severe health issues.
Most opportunistic infections can result in these symptoms. Thus, your health care provider will likely check your blood, urine, or saliva to examine if they are infected by bacteria that result in MAC. The sample will be tested to check the type of bacteria it contains. This is usually carried out through a process referred to as culture. This can last for many weeks. Even when you are infected with MAC, discovering MAC bacteria is difficult.
If your CD4 cell count is not up to fifty, your health care provider may treat you for MAC, even without a specific diagnosis. This is done because this infection, widespread among HIV patients, can hardly be diagnosed.
Treatment of MAC Infection
The bacteria that cause MAC can mutate and build up resistance to a number of the drugs that are utilized to treat it. Mac can be treated by your doctor with the use of antibacterial drugs or antibiotics. The two medications that are commonly utilized are azithromycin or clarithromycin together with three other medications. MAC treatment needs to be given throughout the entire life of the individual. If the individual ceases to use it, the condition will be reversed.
People respond in a different way to anti-MAC drugs. Your doctor would work together with you to discover the particular medication that is most efficient for you.
The MAC drugs that are and their side effects are:
Amikacin (Amkin): Amikin can result in kidney and ear problems; taken as an injection.
Azithromycin or Zithromax: This can result in side effects like vomiting, headaches, sickness, and diarrhea. It is normally taken as capsules or given as an intravenous drug.
Ciprofloxacin (Cipro or Ciloxan): This can cause nausea, vomiting, and diarrhea; taken as tablets or intravenously.
Clarithromycin (Biaxin): This can result in an unsettled stomach, headaches, nausea, and watery poop. It is taken as capsules or intravenously. You must not take a maximum dose of 500 milligrams every day. You are required to take share this maximum dosage two times every day.
Ethambutol as well-referred to as Myambutol can cause nausea, vomiting, vision problems.
Rifabutin, also known as Mycobutin, can result in rashes, nausea, and anemia. Many drug interactions.
Rifampin as well-referred to as Rifampicin, Rifadin and Rimactane can cause fever, chills, muscle, or bone pain. This medication can make your pee, sweat, and saliva to change into red-orange color and this could stain contact lenses. It can interfere with birth control pills and other medications.
Progressive Multifocal Leukoencephalopathy
Progressive multifocal leukoencephalopathy (PML) is a disease that affects the white matter of the brain. It is caused by a virus infection that affects the cells that produce myelin. Myelin is the substance that insulates nerve cells known as neurons. �Polyomavirus JC, which is frequently known as the JC virus, is carried by most people and it doesn�t cause any harm. However, when this virus is present in individuals with low immune systems, like individuals suffering from HIV, it could deteriorate into serious conditions. The sickness is not common but it is frequently found among individuals receiving persistent corticosteroid or immunosuppressive therapy for an organ transplant. It can also manifest in patients suffering from cancers like Hodgkin�s disease or lymphoma.
People who have autoimmune issues like multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus, a few of them treated with biological therapies that permit JC virus reactivation, also have a higher risk of suffering from PML. PML is mainly experienced by people with HIV-1 infection / acquired immune deficiency syndrome (AIDS).
Studies
It was found by studies that before effective antiretroviral therapy, individuals, about 5%, who are positive with HIV-1 ultimately develop PML, which is an AIDS-defining sickness. Nevertheless, the present management procedures for HIV with the use of antiretroviral drugs (ART), which efficiently boost the immune function makes it possible for individuals as much as half of all HIV-PML patients to live. Irrespective of this, they could occasionally suffer from inflammatory reaction in the parts of the brain affected by PML.��
Symptoms of PML
There are many symptoms of PML and they can cause substantial amounts of damage in the brain and may develop within a few weeks to some months. The most significant symptoms are awkwardness, progressive tiredness, and visual, speech, and personality impairments. The increase of the defects results in severe disability and often death of the individual.
Diagnosis of PML
The diagnosis of PML can be carried out through brain biopsy or through a combination of examination of the deteriorating condition of the disease or constant white matter�s lesions. This can be seen through the use of a magnetic resonance imaging (MRI) scan and the discovery of the JC virus in spinal fluid.
Diagnosis
PML generally result to 39 � 50% within the first few months it was diagnosed. However, it varies according to the seriousness of the core disease and treatment received. Individuals who survive PML can be left with serious neurological incapacitations.
Treatment of PML
Presently, the greatest accessible treatment is by reversing the immune-deficient condition, given that there are no efficient medications that obstruct the individual from being infected by the virus that are not harmful and poisonous to the individual. The medications that can be used have serious damaging effects to the individual.
The immune-deficient condition can be reversed with the use of plasma exchange to increase the elimination of the restorative agents that exposes the individual to the risk of suffering from PML. For HIV-connected PML, starting anti-retroviral therapy straight away would be beneficial to the majority of people. Many fresh drugs that were found by laboratory tests to be efficient against infection are being utilized in PML patients with particular authorization of the FDA. Studies are currently being conducted on the use of Hexadecyloxypropyl-Cidofovir (CMX001) to treat JVC due to the fact that it is able to repress JVC by restraining the reproduction of viral DNA.
Tuberculosis and HIV
Tuberculosis (TB) is an�infectious disease�that can be transferred from one person to the other. TB is caused by�bacteria�known as�Mycobacterium tuberculosis. The TB bacteria usually spreads through the air, thus it is an air-borne disease. Individuals infected with HIV frequently suffer from tuberculosis (TB). This is due to the fact that HIV makes their immune system weak. This makes it difficult for their body to fight TB causing bacteria. TB commonly affects the lung of the individual, but it can sometimes affect other parts of the body like the brain, the kidneys, or the spine as well. TB can result in the death of the individual if not properly managed.
How the TB Disease Spreads
TB bacteria pass from an individual to the other through the air. TB germs are transferred to the air when an individual suffering from TB coughs, sneezes, laughs, or sings. Individuals that are close to him or her may inhale the germs and get infection. TB doesn�t spread by sharing cutleries or cups or sharing saliva during kisses.
Not all the people that have TB infection get sick. Some people infected have the germs in their lung in a latent or dormant form. Individuals who have latent infections don�t show TB symptoms. They don�t also transfer it to others. Nevertheless, they can suffer from TB disease eventually, particularly if they are HIV positive. To stop the infection from escalating into TB disease, individuals with latent TB infection are placed on medication.
On the other hand, individuals with TB disease have many active TB germs in their body. They commonly experience the symptoms of TB disease which can include extreme tiredness, weight loss, fever, and night sweats. It can also include cough, chest pain, and they may cough up blood. They may experience a few more symptoms, depending on which part of their body is infected.
Why it is Essential to Test for TB and HIV
It is essential for individuals with HIV to test for TB infection because HIV makes their immune system weak, which could expose them to TB risk.
A weak immune system could make a latent TB germ develop into TB disease very fast. This is why it is very essential as an individual with HIV, which is associated with a weak immune system. Also, if you have either latent TB infection or TB disease and do not know your HIV status, you need to also get tested for HIV to assist your doctor in knowing the best way to treat your TB and HIV infections.
TB Tests
TB test can be conducted either through blood test or through the skin test. For a TB skin test, the medical team makes use of a tiny needle to put the fluid, known as tuberculin, immediately under your skin. This is normally carried out on the lower inner part of your arm. After the test is done, you need to return within two to three days to check if you reacted to the test. If there is a reaction, the amount of the reaction is estimated to find out if you are positive for the TB germs.
For the TB blood test, a sample of your blood is drawn to conduct the test. Your health care provider would inform you how you can get the result of your test.
If Your TB Test is Positive
If you are positive of TB, either through the blood test or through the skin test, what it means is that you are infected with the TB germs. It doesn�t imply you have a TB disease. To confirm if you have TB disease or not, you�d usually be required to take a chest x-ray or sputum (phlegm) sample test.
What Happens�if the Test Result Shows You Have Latent TB Infection or TB Disease?
Both latent TB infection and TB disease can be managed with medication even in people living with HIV. If you have latent TB infection and HIV, your risk for developing the disease is greater. You�d require fast treatment for latent TB infection to prevent TB disease. If you have TB disease, you have to take drugs that treat TB disease. If it is not treated, your health may deteriorate and you�ll die eventually.
Prevalence of HIV/TB Coinfection
TB disease is one of the most common causes of death among individuals with HIV. In the United States, due to wise availability of HIV medications, the number of individual with HIV who contracts TB as well is significantly lower than what is obtained in other countries where the medication use is not as widespread. However, TB patients, particularly those born outside US, frequently still suffer from TB.
Symptoms of TB
Individuals with latent TB don�t experience any disease symptoms. However, if latent TB develops to TB disease, there will normally be signs of the disease.
Regular symptoms of TB disease are:
A constant cough which may result in coughing out blood or sputum
exhaustion
weight loss
Fever
Night sweats
Other symptoms of TB disease may vary depending on the parts of the body affected. For instance, signs of TB infection of the kidneys may contain blood in the urine, and symptoms of TB infection of the spine may contain back pain.
What is the Treatment for TB?
TB treatment in HIV patients is commonly the same as the medication used for individuals who are not HIV positive. TB drugs are used for the prevention of latent TB from developing into TB disease and for the treatment of TB disease. The medicine chosen together with TB medication and the duration of treatment depends on whether an individual has latent TB or TB disease.
Pneumocystis Infections
Pneumocystis jirovecii pneumonia was originally referred to as Pneumocystis carinii pneumonia or PCP. It is an opportunistic infection of the lungs. It is the most common cause of pneumonia and death in AIDS patients. PCP can frequently be prevented with the use of antibiotics.
Pneumocystis jirovecii is a small fungus that lives in the lungs of a number of people. When an individual has a strong immune system it will control the fungus, but if an individual has a weak immune system, the fungus can make the individual very sick. However, it can now be treated. The treatment is most effective if the individual starts it early.
In the US, individuals with HIV/AIDS can hardly contract PCP today than what it used to be in the past, prior to the introduction of antiretroviral therapy (ART). Nevertheless, PCP is still a significant problem against public health and safety. Pneumocystis carinii pneumonia (PCP) is a lung infection caused by a fungus. PCP exists in individuals who have weak immune systems together with individuals with HIV. The initial signs of this infection are breathing difficulty, high fever, and dry cough.
Preventive treatment is extremely efficient for preventing this kind of pneumonia and it is a good idea for all individuals who have low T cell count (normally less than 200�cells per microL),�previous sufferers of PCP pneumonia, or a mouth yeast infection known as thrush.
People who start to receive antiretroviral therapy for HIV may stop taking their PCP preventive therapy when their T cell count is above 200�cells per microL�for at least three months.
Nevertheless, long-term preventive treatment may be essential if an individual develops PCP when the T cell count was higher than 200�cells per microL. Previously, the causative organism of PCP (Pneumocystis jirovecii) is classified by scientists as Protozoan but currently, it is classified as a fungus.
Causes
In individuals with a weak immune system, the cause of this pneumonia may be the same causative factor that causes it in healthy individuals, but the cause of this type of pneumonia is more frequently uncommon causative factors. Frequently,�P. jirovecii�pneumonia is the first symptom that an individual with�human immunodeficiency virus�(HIV) is already infected by AIDS.
Other fungi like Aspergillus and Candida; bacteria like Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae, and viruses like cytomegalovirus and herpes simplex virus are also causative factors of pneumonia in individuals who have a weak immune system.
The bacteria that cause Pneumonia may include bacteria�Streptococcus�pneumoniae, also referred to as Pneumococcus.
How Does Pneumocystis Transmit?
PCP is a communicable disease. It is transferred from one individual to the other through the air. Pneumocystis fungus can stay in the lungs of healthy individuals, as well as in some individuals with a weakened immune system without exhibiting any symptoms. A number of individuals are exposed to the fungus in their childhood, but they probably don�t get sick because they have a strong immune system. PCP is transmitted to a person who is exposed to the sufferer of PCP or a person who carries the fungus in the lungs but without a visible sign.
Symptoms of PCP
The symptoms are usually a fever, breathing difficulty, and a dry cough. These symptoms can come fast or a bit slower in some instances. It may limit the supply of enough oxygen to the blood, which can result in serious breathing difficulty. The individual may also experience chest pain, chills, and exhaustion. Get in touch with your doctor if you suspect your symptoms are connected to PCP.
Who is at Risk of Suffering from PCP?
PCP can hardly affect healthy individuals. They could carry the fungus infection in their lungs without causing any symptoms. At any particular time, roughly 20% of people can carry the fungus. They�d normally be destroyed by a strong immune system after many months.
PCP is common in individuals with weak immune systems because of their body�s inability to fight against the disease. Roughly 40% of people with PCP have HIV/AIDS. The rest of the individuals who suffer from the condition are under medical treatment that lowers their immune system like:
Organ transplanting
Cancer of the blood
Inflammatory diseases or autoimmune diseases like lupus or rheumatoid arthritis
Stem cell transplanting
Prevention of PCP
No vaccine prevents PCP. However, prescription medication like trimethoprim/sulfamethoxazole (TMP/SMX), also known as co-trimoxazole, can be used to prevent the occurrence. The medication is also known through the following brand names; Bactrim, Septra, and Cotrim. There are alternative medications for individuals who cannot manage TMP/SMX like dapsone, atovaquone, and pentamidine, which are aerosol taken by inhalation into the lung.
Individuals suffering from HIV, stem cell transplant patients, and people for a solid organ transplant have usually prescribed the medication for PCP.
Test and Diagnosis
PCP can be diagnosed through the following methods:
Chest x-ray
PCP can be diagnosed with Polymerase chain reaction (PCR)
A blood test to detect ?-D-glucan
Microscopic examination of a sputum (thick or dirty mucus) sample obtained from the lung of the individual. It can either be coughed out or obtained through a bronchoalveolar lavage.
Treatment
The most common types of treatment given for PCP are:
Antibiotics, antiviral, or antifungal drugs
Management of the immune system issue of the individual
The treatment given usually depends on the
Particular immune system issue
Seriousness of the condition
The causative organism
The first treatment is usually a broad-spectrum antibiotic. Viral or fungal medication may be added if the condition does not improve.
Infections can frequently happen to any person depending on several circumstances, however, in people with HIV/AIDS, infections can happen much more frequently and these can be much more severe. These are commonly referred to as opportunistic infections or OIs. As previously mentioned in the article above, HIV/AIDS tremendously affects a person’s immune system, making it less capable of fighting off infections. Several types of bacteria, viruses, fungi, and other organisms that don’t commonly cause infections in healthy people can ultimately make people with weakened immune systems sick, including people with HIV/AIDS. Here, we summarize a variety of the most common opportunistic infections or OIs that can affect people with HIV/AIDS. It’s essential to seek immediate medical attention from a qualified healthcare professional if you experience any symptoms. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas*& New Mexico*�
Crohn�s disease is an inflammatory bowel disease (IBD). IBDs are health issues that affect the digestive tract by causing inflammation that lasts longer than an average upset stomach or mild infection. Most people think that the digestive tract only consists of the stomach, which stores and breaks down food, as well as the small and large intestines, which take the waste out of our systems through urine and feces. But it�s more than just that. The mouth and esophagus are also part of the digestive tract and problems within can make things difficult and painful down the line. While researchers have been researching Crohn�s disease for several decades, they have no undisputed answer on the cause of this disease. This article will take you on a journey through the history, causes, symptoms, diagnosis, and treatment of Crohn�s disease as well as what the future holds. According to the Crohn�s and Colitis Foundation of America, as many as 700,000 people in the United States suffer from Crohn�s disease while 3 million total have some sort of IBD. That is equivalent to the number of people living in Washington D.C.
Understanding Crohn’s Disease
Crohn�s disease was first described by Dr. Burrill B. Crohn in 1932 with the assistance of Dr. Leon Ginzburg and Dr. Gordon D. Oppenheimer. Crohn was born in 1884 in New York City as one of 12 children. He became a doctor because of the sympathy he had for his father who suffered terrible digestion problems. Crohn was part of an enormous group of doctors who joined many reputable medical schools at the beginning of the 20th century, graduating from Columbia University�s College of Physicians and Surgeons in 1907. At the university, he earned an M.A., Ph.D., and an MD� for his research on an intra-abdominal hemorrhage. He could not pay the high cost ($35) for the former two degrees because he did not want to ask his father for the money. He spent 2.5 years as an intern at the illustrious Mount Sinai Hospital, one of only 8 interns selected from 120 candidates. He found humor in his chosen profession which he quoted in his biography saying, �It has been my misfortune (or perhaps my fortune) to spend most of my professional life as a student of constipation and diarrhea. Sometimes I could wish to have chosen the ear, nose, and throat as a specialty rather than the tail end of the human anatomy.�
Most gastroenterologists of the time were surgeons, but Crohn�s research was such that he joined the American Gastroenterological Association in 1917, having been mentored by Dr. William J. Mayo whose clinic remains one of the foremost bodies of American medical knowledge more than 100 years later. Although he was married with two children, Crohn was consumed with his work and his patients, with daily and nightly house calls. Perhaps even more important was his work on �Affections of the Stomach� which he published in 1928. He worked with Dr. Jesse Shaprio at Mount Sinai who suffered from IBD himself. Crohn found that many Jews had the condition and, since Mount Sinai admitted many of them, he found plenty of patients to study. He ended up as the first head of Mount Sinai�s Gastroenterology Clinic and was associated with the hospital for 60 years. He joined the efforts of surgeon Dr. A. A. Berg along with Ginzburg and Oppenheimer to start a project dedicated to bowel tumors and strictures. Their combined research allowed Crohn to present a paper to the American Gastroenterological Association in May 1932 in Atlantic City called �Non-specific Granuloma of the Intestine� followed by a second called �Terminal Ileitis: A new clinical entity�. Crohn preferred the term regional ileitis because he believed it only existed in the distal part of the small intestine and was worried people would assume it was fatal when they saw the word �terminal�. Soon after, the term Crohn�s disease became the catch-all for any terminal or regional enteritis. Crohn did not want the �honor� but his colleagues insisted.
The history of the disease is recorded as far back as 850 AD, affecting England�s King Alfred. The populace believed that he was being punished for his sins, but the presence of fistulas and pain from eating speaks otherwise. About 150 years before Crohn�s disease got its name, an Italian physician named Giovanni Battista Morgagni described the disease in 1761. Crohn officially retired in 1948 but continued practicing medicine well into his mid-90s. He passed away on July 29, 1983, 11 months short of his 100th birthday. In his final year, his friends, family, and colleagues began the creation of the Burrill B. Crohn Research Foundation at Mount Sinai Hospital.
What Causes Crohn’s Disease?
Crohn�s disease has troubled doctors and researchers for decades because an exact cause can’t be found, which limits their ability to fully treat it. Poor diet habits together with high levels of stress were the original leading cause for the health issue, but over the years those have come to be thought of as factors that aggravate the condition, not cause it. Two factors that stand out in today�s research are heredity and a malfunctioning immune system.� Like many major diseases, if someone in your family has suffered from Crohn�s disease, there is a much higher chance that you will too. Anytime you go to a new doctor, this should be one of the first things you inform them of when filling out a family history chart. That way if any of these symptoms do manifest, your doctor will have a knowledge base from which to proceed. Despite believing that genetics plays a fundamental part, currently, doctors can’t predict who will get Crohn�s disease based on family history.
Another leading theory is that an invalid response by the body�s immune system can cause Crohn�s disease to develop. The theory suggests that some bacteria or viruses can trigger Crohn�s disease by causing an abnormal immune system response when the body is fighting it off. The response causes the immune system to attack its own cells in the digestive tract, leading to the inflammation. Crohn�s disease attacks people of all ages, genders, and ethnicities, however, these characteristics are thought of as leading to a greater chance of getting the condition.
Geography:�People who live in urban/industrialized areas are more likely to develop Crohn�s disease than those living in rural areas. This suggests that diets full of refined foods or heavy in fat are more likely to trigger Crohn�s disease, while people eating diets that are more fresh and free from additional chemicals are more likely to avoid it.
Family History:�Although plenty of people get Crohn�s disease without a single relative suffering the same, as many as 1 in 5 people with Crohn�s disease (20%) have a relative who also has it.� Between 1.5% and 28% of people with IBD have a first-degree relative (parent, sibling, child) that have an IDB as well.
Smoking:�Like many other diseases, smoking augments the severity of Crohn�s disease and is the single most controllable risk for developing it. No one can make you stop smoking, but if you are experiencing the initial signs of Crohn�s disease, it is the best thing you can do for yourself.
Ethnicity: One of the most frustrating parts of Crohn�s disease is the randomness it seems to possess in who it strikes. Caucasians are the highest risk group, particularly those of Eastern European Jewish descent. However, African-Americans and people of African descent that live in the United Kingdom have seen their numbers consistently rise over the past decades when it comes to developing Crohn�s disease.
Age:�Another rarity. Anyone at any age can Crohn�s disease, but it is usually diagnosed before the age of 30, suggesting it is tied to growth and maturity. It is among the rare diseases where your chance of developing it lessens as you get older.
Ingesting anti-inflammatory medications: Nonsteroidal medicines that include ibuprofen, naproxen sodium, diclofenac, etc., can lead to inflammation of the bowels, which worsens Crohn�s disease. If you have the symptoms of Crohn�s disease, do your best to avoid the likes of Aleve, Advil, Voltaren, Motrin IB, etc.
What are the Symptoms of Crohn’s Disease?
As Crohn�s disease begins to take hold of a person�s body, they will experience abdominal pain, fatigue, weight loss, malnutrition, and severe diarrhea. It does not follow a set pattern as Crohn�s disease can affect different parts of the digestive tract for different people. While there are many similarities, it is rare for two cases to be exactly alike. Crohn�s disease causes inflammation in the digestive tract that spreads deeper and deeper in the bowel tissue of the affected areas. Normal medicines can lessen the intensity of the pain, but the infection runs too deep for them to be able to do much more. These symptoms can be extremely painful, embarrassing for those who suffer from fatigue or severe diarrhea, and debilitating, making the sufferer miss days, weeks, or even months of work or school while seeking treatment and learning how to cope. The most commonly affected parts of the body for someone suffering from Crohn�s disease are the small intestine and the colon. The biggest problem with diagnosing Crohn�s disease early on and starting treatment for it is that many of its symptoms are similar to a host of other maladies, including:
Cases of diarrhea
Fever
Abdominal pain/cramping
Appearance of blood in the stool
Fatigue
Loss of appetite
Unexplained weight loss
Mouth sores
Fistulas around the anus causing pain or drainage
In most cases, the appearance of one or even a few of these symptoms could be attributed to any number of infections or viruses. A good doctor will rule out those first, often with a simple medication plan. If progress is not made, then the potential of Crohn�s disease heightens. The surefire symptoms that demand a trip to the doctor include: blood in your stool, multiple episodes of diarrhea that don�t stop with the application of over-the-counter medications; a fever that lasts more than two days without an explanation; losing weight without meaning to or without a proper explanation (food poisoning, a stomach bug, etc.) Loss of appetite, undereating, and fatigue are all signs of malnutrition. When your body isn�t getting the right nutrients from the food you eat, it is difficult for it to fight off illnesses and infections. Left untreated, the symptoms of Crohn�s disease become extremely serious, including:
Inflammation of the liver and/or bile ducts
Inflammation of joints
Inflammation of eyes
Inflammation of skin
In children, delayed growth and/or sexual development
What is the Diagnosis of Crohn’s Disease?
When one or more of the symptoms persist and your physician has ruled out more pedestrian causes, attention must focus on the possibility of Crohn�s disease as the cause. Different symptoms can mean different types of Crohn�s or even a different type of IBD. Types of Crohn�s disease include:
Ileocolitis:�This is the most common form of Crohn�s disease. It affects both intestines � the end of the small intestine, which is also known as the terminal ileum. Common symptoms include diarrhea, cramping, pain in the middle and lower-right abdomen, and significant weight loss.
Ileitis:�This type of Crohn�s disease only affects the ileum. Its symptoms are generally the same as ileocolitis. In severe cases, fistulas and inflammatory abscesses can appear in the lower right part of the abdomen.
Gastroduodenal Crohn�s Disease:�Affects the stomach and the beginning of the small intestine which is known as the duodenum. Symptoms can include weight loss, loss of appetite, frequent vomiting, frequent fits of nausea.
Jejunoileitis:�This type of Crohn�s disease affects the jejunum, which is the upper half of the small intestine. Patchy areas of inflammation in the upper half of the jejunum are typical of this type of Crohn�s disease. Symptoms are not as severe in this form, but no less important to have diagnosed. They include mild-to-intensive pain or cramps following meals in your stomach or abdomen; bouts of diarrhea; fistulas forming long term in severe cases or if the inflammation goes a long time without being treated.
Crohn�s Granulomatous Colitis: This type affects only the colon. Typical symptoms are diarrhea, rectal bleeding, conditions around the anus that include ulcers, fistulas, and abscess, and joint pain, or skin lesions.
No single test confirms a diagnosis of Crohn�s disease. Other conditions have the same symptoms, including bacterial infections, so it might take some time to actually get the diagnosis despite days, weeks, or months of the symptoms.
What Can You Expect From Your Doctor?
The first thing a doctor will do is to do a standard physical exam of your entire body including questions on your family history, daily routine as well as diet and nutrition. Answering all of these completely and honestly will allow your physician to rule out or narrow in on certain maladies a lot quicker. Diagnostic tests will come in the form of blood draws and stool samples. These can eliminate the presence of a lot of diseases and focus in on what might be the case. If those are inconclusive, most doctors will likely perform X-rays on your upper and lower GI tract, looking for things like inflammation and ulcers. A contrast test might also be ordered to see the clear difference between what should be there and what should not. Remember to bring a friend or family member with you to these appointments, as it can be overwhelming to go through all the possibilities and potential diagnosis of Crohn�s disease. As the tests progress, it is a good idea to contact your insurance company and let them know what is going on so they can give you information on what tests are covered and which might not be. Make sure to write down as much information as you can with your doctor and ask questions that you don�t understand.
If the initial X-rays are not successful in narrowing down the issue, your doctor might recommend an endoscopy. This is a procedure done by putting a tiny camera mounted with a light to look at your GI tract and intestines. They are much more invasive than chest X-rays, but many technological advancements have made it much more tolerable. A GI doctor can use a bit of local anesthesia and a small camera to deaden your throat and disable your gag reflex. This allows the GI to view your mouth, esophagus, stomach, and the first part of your small intestine, known as the duodenum, looking for tell-tale signs of inflammation or ulcers.
A second endoscopy is a bit more of a chore. Also known as a colonoscopy, it requires the total evacuation of your GI tract before doctors can take a look. This means you�ll take medicine to clear it out, which will induce quite a few trips to the bathroom and be none too pleasant. This procedure usually requires drinking a liquid that acts as a fairly extreme form of laxative and will require you to take time off from work or school for at least a day while its effects take place. Once you get to the medical facility, you will be given anesthesia to knock you out, which is a good thing as the camera will enter through your rectum and move up to look at your colon. If there are any unusual structures present in either endoscopy, doctors might want to collect a biopsy of your colon or another area. This is done by using a tool to remove a small bit of tissue from inside the intestine or inside some other part of your GI tract for analysis. There is zero pain associated with a biopsy.
During the colonoscopy, the doctor might want to do another procedure known as a chromoendoscopy. In this procedure, a blue liquid is sprayed into the colon. It reveals slight changes in the lining of your intestine which can be polyps or other changes that are believed to be precancerous. This means they might be precursors to changes to your body that can become cancer cells. If polyps are discovered, they can be removed and a biopsy is taken to determine if they are benign or malignant. If the blue liquid is used, bowel movements will have a definitive blue tinge to them for the next few days.
There are some parts of your small intestine that cannot be seen during either colonoscopy or endoscopy. This requires small intestine imaging which works using an oral contrast � something you drink � in conjunction with computer tomography (CT) scan or a magnetic resonance imaging scan (MRI). As radical as it sounds, this can involve swallowing a camera that size and shape of a bill which then takes pictures of your small intestine and bowel as it moves through your GI tract. It is harmlessly expelled during a future bowel movement. If parts of the intestine are too hard to reach, a balloon endoscopy can be used. It�s not a real balloon, but the concept is the same. The displacement of the structure with an air-filled object creates space for the camera to get in close and record.
What is Crohn�s Disease Activity Index (CDAI)?
The Crohn�s Disease Activity Index (CDAI) is a research tool that allows researchers, doctors, and patients to quantify how painful symptoms of Crohn�s disease are at any given time. It was first developed by W.R. Best and his colleagues at Illinois�s Midwest Regional Health Center in 1976. The index has eight factors that it considers, each weighted and then added together to reveal a final score. The CDAI helps major studies diagnose how well the medicine is effective for people suffering from Crohn�s disease. It is excellent for determining the quality of life for Crohn�s disease sufferers to give doctors a good grasp on how much pain a person can endure before their quality of life really begins to suffer. The eight variables involved in the CDAI are:
Percentage deviation from standard weight
Hematocrit of <0.47 (men) and 0.42 (women)
Presence of abdominal mass (0 if none, 2 if questionable, 5 if definite)
Is the patient taking Lomotil or opiates to reduce bouts of diarrhea?
How is the patient feeling in general on a scale from 0 (well) to 4 (terrible). This is accounted for every day for seven days straight.
Presence of complications
Abdominal pain graded from 0 (none) to 3 (severe) for seven days straight.
A recording of the number of liquid or soft stools for seven straight days.
These eight factors are all assigned different weights, with the presence of complications and taking of Lomotil or opiates getting the highest weights (x30 and x20). Points are also added for things like joint pain, inflammation of the irus, anal fistulas, and fissures, a fever, etc. When all of this information is tallied a number, usually three digits are presented. If a person has a score of more than 450, they are considered to have severe Crohn�s disease and actions are taken accordingly. If the CDAI is less than 150, a person is considered to be in remission. If a person�s CDAI score drops 70 or more points be responding to treatment. A working version of the CDAI scale can be found here. Although it is very helpful, the CDAI has also been met with some criticism. The fact that it does not consider the typical quality of life, fatigue, endoscopic factors, protein loss, or other systemic features.
What are the Complications of Crohn’s Disease?
Similar to many other severe diseases, the lack of treatment of Crohn�s disease or the worsening of it despite treatment can lead to several other complicated illnesses, some of them life-threatening. They include:
Bowel obstruction: When Crohn�s disease inflames the digestive tract it can thicken the intestinal wall, which causes parts of the bowel to develop scar tissue and begin to narrow, making for irregular bowel movements. If the passage becomes too narrow it will actually block the flow of your digestive system, causing its contents to become stuck and form a barrier of their own. This will start as constipation but will eventually become obvious that something more severe is going on as treatments are applied. Surgery, usually done quickly after the diagnosis is made, will be required to remove the part of your bowel that has become scarred. If the bowel obstruction is complete, it requires emergency surgery. This sort of surgery is done under general anesthesia, meaning you are asleep for the procedure and will not feel any pain as it is performed. A surgeon makes a cut into the belly to see the intestines. Sometimes this is done laparoscopically to minimize how much cutting has to be done. From there, the surgeon will find the part of your intestines that is blocked and unblock it. This is not the extent of the procedure, however. If any part of the bowel is damaged, it must either be removed or replaced. This is known as bowel resection. If it is removed, the healthy �ends� on either side of the removed section are connected together, using either staples or stitches, which can either dissolve or be removed with another procedure, this one much more likely to involve laparoscopy. There are some incidences where the ends cannot be connected because such a large part of the intestine has to be removed. When this happens, the surgeon brings out one end through an opening in the abdominal wall via a colostomy or ileostomy. The key is to perform the surgery before blood flow in the bowel is affected. The surgery has many risks including more scar tissue forming, damage to nearby organs, and more bowel obstructions.
Ulcers:�When parts of the body are chronically inflamed, they lead to open sores that do not heal like normal. These are called ulcers and can be found almost anywhere in your body, inside or out. For people suffering from Crohn�s disease, they can be found in the mouth, the anus, the stomach, or in the genital area. Ulcers along the GI tract are often the first sign of the disease, although since they are undetectable except in the mouth, for most people, they are often missed until other symptoms form. Ulcers can also form in your duodenum, appendix, small intestine, and colon. A similar condition, known as ulcerative colitis, only forms in the colon and is not as serious as Crohn�s disease. If an ulcer breaks through the intestinal wall it can form a fistula, a connection between the intestine and the skin or different parts of the intestine. This is a very dangerous condition that may lead to food bypassing your bowels or even bowels draining onto your skin. If they develop into abscesses they can be life-threatening. Ulcers can also cause a person to become anemic if there is more than one of them in the small intestine or the colon. This can cause frequent loss of blood and can require surgery.
Anal Fissure: This is a small tear in the tissue of your anus or the skin around it that can become infected. It results in painful bowel movements. It can heal naturally, but left untreated threatens to come to a perianal fistula.
Malnutrition: Anyone suffering from diarrhea, abdominal pain, and cramping is likely to not be getting enough nutrients into their body for proper function. Common results are anemia from not intaking enough iron or enough B-12. If the small intestine is inflamed, it can cause problems with digesting food and absorbing nutrients. If the problem is in the large intestine, including the rectum and the colon, the problems include the body�s inability to absorb water and electrolytes. What causes malnutrition? There are several ways that it can form. One that most people have experienced over the course of their lifetimes is severe diarrhea. Have you ever had food poisoning that resulted in multiple incidents of bad diarrhea or vomiting? The next time you step on a scale you might be astonished to see that you have lost several pounds in a single day, maybe even as many as 10 or 12! When your body detects something in your GI tract, it makes every effort to evacuate it one way or another. This results in the body using fluids to transport the foreign elements out of the system and can lead to dehydration as fluids, nutrients, and electrolytes such as zinc, phosphorus, magnesium, potassium, and sodium get ejected along with it. � Other causes of malnutrition include abdominal pain and nausea. If you�re a woman who has ever been pregnant and dealt with morning sickness, you know how these feel, and when they strike, eating is the last thing on your mind. However, it also makes it tough for your body to gather sufficient nutrients and the correct number of calories, which makes it weaken over time. Rectal bleeding, both painful and embarrassing, also causes malnutrition because the ulcers in your intestines are leading to deficiencies. Frequent trips to the bathroom can also cause malnutrition because people will seek to cut down on this habit by eating less to avoid embarrassment. But cutting back on your body�s calorie intake can lead to malnutrition and weight loss. An even tougher pill to swallow is that certain IDB medicine damages your ability to say nourished. Prednisone, which is a common corticosteroid, can cause a decrease in healthy muscle mass over long-term use. Other treatments, like sulfasalazine and methotrexate, can interfere with the absorption of folic acid, which is crucial in healthy cell growth.
Colon cancer:�The �Big C� rears its ugly head in association with Crohn�s disease, unfortunately. Having Crohn�s disease increases your risk of colon cancer. People without a family history of Crohn�s disease or colon cancer are advised to get a colonoscopy every 10 years beginning at age 50 to check. If you have a family history, ask a doctor about having it done sooner and more frequently. Colon cancer starts in the colon or rectum when cells grow abnormally. Most starts as a growth called a polyp on the inner lining of the colon or rectum. There are two types of polyps: Adenomatous and Hyperplastic/Inflammatory. The latter are generally not cancerous and are more common. The former sometimes change into cancer. If they are larger than 1 cm, this is more often the case, or if more than two are found. A condition called dysplasia also is a warning sign of cancer. This means that after the polyp is removed, there are areas in the polyp or in the lining that don�t look normal, suggesting they are cancerous in origin.
Other health problems:�Any number of maladies can befall someone stricken by Crohn�s disease. How it affects the rest of the body is different from person to person. Common problems can include anemia, skin disorders, arthritis, liver disease, and gallbladder disease.
Malabsorption:�A complication of malnutrition, it makes it difficult for vital nutrients such as fats, sugars, vitamins, minerals, and proteins to make it through the small intestine. Inflammation of the intestines, a symptom of� Crohn�s disease, can also make this possible.
Decreased Bone Strength:�A complication of malnutrition, it increases your risk of bone fractures. If your body is not getting enough Vitamin D, is not absorbing enough calcium, or you have long-term inflammation, this is more likely to happen.
Growth Delays:�A dangerous complication for kids suffering from� Crohn�s disease is a lack of growth due to IBD. About one-third of kids with� Crohn�s disease and 1/10th of those with ulcerative colitis in the US will be shorter than expected. Children with either of these diseases should have a dietitian consulted by their parents.
What is the Treatment for Crohn’s Disease?
Hearing that there is no known cure for Crohn�s disease can be a debilitating blow to people suffering from it. However, developments in therapy allow for the ability to greatly reduce it symptoms and even invoke long-term remission in some patients. Given proper treatment and with a commitment by the sufferer, people afflicted with Crohn�s disease can function well and lead a long, healthy life. The good news is that if one treatment option does not work well, there are others to try. It�s a balancing act for most people, and the need to titrate that balance between medicine, changes to their diet and nutrition routines, and sometimes surgical procedures is the best way forward to getting on track and healthy.
Medication: Medication is what most people think about when they get sick, and such is the case here. Medicine for Crohn�s disease is designed to suppress the response of your immune system to the inflamed parts of your GI tract. Suppressing that inflammation can go a long way to reducing the pain from fever, pain, and diarrhea. It also gives your body time to heal up. The medication can help you avoid flare-ups (see below) and extended periods of remission to great and greater lengths of time. We�ll talk about remission later in this book.
Combination Therapy:�Combination therapy is exactly what it sounds like; using more than one source of treatment to get Crohn�s disease under control. This sort of treatment can also up the risk of side effects or even toxicity, so your doctor needs to analyze both you and the treatment plan to see what makes the most sense.
Diet & Nutrition:�The amount of diseases that get dramatically better when one starts to make drastic changes in their diet and nutrition habits is truly astounding. Good nutrition via eating the right kinds of foods for your specific form of Crohn�s disease can really lessen the painful symptoms of the disease and prevent flare-ups. Understanding your body�s needs in terms of proteins, fats, carbohydrates, water, vitamins, and minerals can give you a great education on why you�re developing certain side effects and how to lessen their effect. Much like when you get food poisoning or an upset stomach, reverting to a bland diet � the universally known Bananas, Apple Sauce, Rice, Toast (BRAT) method is a great way to lessen the discomfort that may occur when eating spicy foods or those that cause flare-ups.
Surgery:�No one wants to have a surgery especially in an area as sensitive as your GI tract. However, statistics say that as many as 66%-75% of people with Crohn�s disease will require surgery at some point. That number is daunting, but since most people don�t understand or can identify that they have Crohn�s disease until they have suffered inflammation of the intestines. Surgery is necessary when medications are not working or if the inflammation has turned into an obstruction, fissure, or fistula, that is not allowing your intestines or anus to work correctly. As mentioned earlier, these surgeries include removing a diseased portion of the bowel, known as resection, and taking the remaining healthy portions and moving them together (anastomosis). Although this sort of surgery can make a huge difference and send someone suffering from Crohn�s disease into remission, it is not a cure. Post-surgery statistics show that 30% of patients that have surgery related to Crohn�s disease have a return of symptoms within three years, and as many as 60% have a return of symptoms within 10 years.
How Can You Avoid and Contain Crohn’s Disease Flare-ups?
Flare-ups are an unfortunate but expected part of suffering from Crohn�s disease. Very rare are the patients who are diagnosed with Crohn�s disease, get treatment, and they are in remission for the rest of their lives. Eventually, a flare-up will come to any Crohn�s disease sufferer. Being prepared and understanding the causes is very important to keep a flare-up from becoming a longer-term suffering session. When a flare-up does happen, sufferers of Crohn�s disease must be on their guard to take care of themselves but also to identify possible causes of the flare-up. Doing so will make it much easier to avoid them in the future.
The first thing to check on when you have a flare-up is your recent diet. Lots of foods can exacerbate your GI tract and cause inflammation anywhere along the tract, from your mouth to your intestines. Foods that contain spices like garlic, chili powder, onions, paprika, and so on are among the types of food that can easily agitate the digestive tract and cause inflammation that can cause severe pain and severe diarrhea. A great way to pinpoint what foods might be causing the flare-up is to keep a food diary in which you record everything you eat. This way you can really target foods that when consumed are followed by a flare-up. It might not even be food but an actual ingredient that causes the flare-up. Knowing what foods cause these symptoms in you makes it easy to avoid them. If you are struggling to define what foods are safe for you and which ones trigger your Crohn�s disease, ask a doctor about the possibility of consulting a dietician about the matter.
If you�ve ruled food out as a probable cause of a flare-up, your next best bet is to analyze your patterns for taking medicine. Skipping a dose, taking the wrong dosage, or even taking pills at different times than normal can trigger a reaction or lessen the potency of the drug�s effectiveness at quelling your Crohn�s disease symptoms. If you are an adult or a teenager, the only person who can make you take your pills on time and in the correct dosage is you. If you are a parent of a child with Crohn�s disease, you must ensure they are taking the exact dosage at the exact time each day. If you are finding your current dose to not be taking good enough care of your symptoms, you must contact your doctor, explain what is going on, and work with them to find a solution or possibly change the medication itself, how often you take it, when you take it, or the dosage you are taking. Doctors want to help you find that healthy medium between being too drugged up and being in too much pain.
If it�s not your Crohn�s disease medication bothering you, it might be another form of medication, particularly nonsteroidal anti-inflammatory drugs (NSAIDS). Despite that tongue-twister of a name, these are some of the most well-known drugs in the world with more common names like aspirin and ibuprofen. Unfortunately for sufferers of Crohn�s disease, these analgesics also have painful side effects that can irritate the bowel and kick up inflammation quickly. If you suffer from frequent fevers, headaches, or other body pain, ask your doctor if it is safe for you to take acetaminophen (commonly found in Tylenol) to avoid the NSAIDs.
Another medicine that can cause flare-ups are antibiotics, frequently prescribed to treat bacterial infections. If you�ve ever been prescribed antibiotics, you�ll know that the doctor, the nurse, and the pharmacist will all insist you take them with food to lessen the chance of an upset stomach. This still happens in even the healthiest of people because it changes the balance of the bacteria in your intestines. That can cause diarrhea, and when diarrhea appears in the tract of someone suffering from Crohn�s disease, it can spell trouble.
If your diet is good and you are avoiding medicines that are known to cause flare-ups, there are still two more places to look among the likeliest causes. The first is if you are a smoker. Look, we all know that smoking is bad for you for any number of reasons, increasing your risk for stroke, heart attack, and lung cancer among others. That same risk holds true for patients suffering from Crohn�s disease. Introducing smoke and tobacco to your digestive system is one of the worst ideas you can have. If you are tempted to smoke while going through Crohn�s disease, be aware that you are much more likely to need surgery because of it. One other cause of flare-ups is increased stress. Stress was originally thought of as one of the causes of Crohn�s disease, but in fact, it is more commonly believed to be an agitator of the disease. If you are struggling with stress and can feel it spilling over into you Crohn�s disease, consult a doctor on how to incorporate stress-management techniques. If your need is immediate, things like taking a warm bath or a long shower can help relax your muscles. Other ideas are to exercise or simply take a walk to pull out the strain from muscles you did not even know you were clinching. You can also try yoga or meditation, for which there are thousands of online resources to get you started.
What Can You Do When You Have a Crohn’s Disease Flare-Up?
It�s hard not to feel stress and/or panic when you have a flare-up of your Crohn�s disease. Some last a day, some for a week, and some a month as it really depends on the person, the circumstances, and how well they are able to handle it. Although it has no true healing powers, a positive frame of mind that this condition is temporary and that you will improve can greatly affect the mindset of a person suffering a flare-up.
Maintain a healthy diet:�It could very well be something you ate that is driving you into a flare-up, but that does not mean you should stop eating or try some radical purge diet. Proper nutrition is the essential foundation of dealing with Crohn�s disease on a day-in, day-out basis. If you have bouts of diarrhea that drain your body of fluid, adjust accordingly by increasing your fluid intake and eating bland foods that are much less likely to have spicy ingredients or high concentrations of fat that can lead to more inflammation.
Stay regular with your diagnostic tests:�When you are first diagnosed with Crohn�s disease and your doctor provides you with prescriptions and treatment plans, part of that plan should be regular scheduled diagnostic tests to see how your body is faring. If you have a flare-up, call your doctor and let them know about it, as well as any guesses on your part on what could have caused it. The doctor might want to move up a diagnostic test to see what sort of side effects are occurring and why you had the flare-up, this can allow the doctor to analyze what is causing it and how to prevent it from happening again.
Set up a support system:�No one should have to go through any disease along, particularly one like Crohn�s disease that has so many miserable side effects. No matter your age, your marital status, or what you do for a living, you�ll need a network of friends and family you can rely on for emotional and physical support when you suffer a flare-up. This will involve an initial period where you let them know what you are suffering from and give them transparency and knowledge about what Crohn�s disease is and what it does to people. While it can be very embarrassing, the more open and honest you are with the people who care about you, the easier it will be to reach out when you need help. This can be anything as simple as driving to the doctor or as serious as picking your kids up at school because you have to go to the emergency room. Other times, it�s just someone who can lend an ear and talk when you are frustrated by the flare-up in particular or what the future might bring. Make sure at least one member of your support network works or lives close-by in case of an emergency.
Maintain a great relationship with your doctor: We all get how busy most people are. You find a doctor, get your prescriptions filled, and see them again in 6-12 months. That�s not how things work when you�re battling against Crohn�s disease. Having a doctor you know, trust, and feel confident about in his or her ability to accurately and honestly get you on the right path from the get-go. This extends past your primary care physician as well. Getting on good terms with his or her office staff front desk, nurses, any other physicians, such as a dietician or a counselor can have enormous benefits down the line.
Respect your prescribed treatment: Too many people get into their heads that they know the best overtime on how their treatment should go. These are the types that end up altering their dosage, not taking medicine at the right time, or not taking it altogether. Doctors aren�t just diagnosing you to hear themselves think. They are using all the tools at their disposal to make you feel better and let your body heal. Consider that the next time you don�t feel like taking a pill.
Try Corticosteroids:�This medication is often prescribed to treat flare-ups for the short term. They are not recommended over a long period of time as patients can either get addicted to them or become resistant to them.
Get better sleep:� Research has shown that patients with Crohn�s disease are more likely to have relapses if they do not get enough sleep at night. The poor sleeping in a study of 3,173 adult patients with IBD found that many 60% of patients suffering from flare-ups reported poor sleep, linking it to the likes of depression, tobacco use, and use of corticosteroids.
What is Remission Like with Crohn’s Disease?
Remission is the stage of Crohn�s disease where the symptoms go dormant. The inflammation which infects your digestive tract goes away and the damage to your bowel, colon, and other parts of the GI tract ceases. Your immune system stops attacking your own body and returns to its normal functioning. During this time, you will notice fatigue and pain diminishing and you will cease having bouts of severe diarrhea. Diagnostic blood tests by your doctor will likely show your inflammation levels have returned to normal and lesions found in your bowel, colon, stomach, anus, esophagus, and mouth will close and start to heal. No one can say what causes remission or how long it lasts, but it clearly is a cycle. After the first flare that triggers the diagnosis of Crohn�s disease, about 10%-20% of patients report long-term remission. This statistic is on the uptrend thanks to advance studies and research that better prepare doctors and patients to deal with Crohn�s disease more rapidly and effectively. There are several types of remission associated with Crohn�s disease, with accompanying characteristics. They are:
Clinical remission: This means you have zero symptoms associated with Crohn�s disease at the time. This can happen naturally or it can be the result of the diligent taking of medicine. Note that if your remission is a result of taking corticosteroids, it�s not really considered remission, mostly because these drugs are meant only for short-term use as they can become addictive or the body can become resistant to them.
Endoscopic remission:�This means your doctor does not find any sign of disease when he checks your colon during an endoscopy. If there is no inflammation and no lesions or polyps are present. This can also be termed as deep healing or mucosal healing. It does not really guarantee remission however, as there is a lot more to Crohn�s disease than simply what is going on in the colon. Inflammation can occur anywhere on the GI tract, but the colon is a major part of this.. Nevertheless, the colon is a major player in the disease and is one of the most painful parts of the process, so a clean bill of health there is worth celebrating.
Histologic remission: This term refers to the condition where cells are removed from your colon during endoscopy and tested as normal under a microscope. This indicates there is no presence of cancer nor inflammation commonly associated with Crohn�s disease. This remission is discovered when a follow-up to a surgical procedure is done and a lack of disease activity is found, especially is the procedure involved an ileocolonic resection, which is the most common surgery associated with Crohn�s disease. In this procedure, the area where the small and large intestines meet each other, known as the terminal ileum, is removed.
Biochemical remission:�Blood and excrement do not contain substances that signal the presence of inflammation. This is proven by blood tests and stool samples.
The path to remission is different for every Crohn�s disease patient, which can make it all the more vexing when you have a much harder time than someone else in achieving it. Doctors will try lots of different medications to get you going, while others will try more aggressive routes. Here are some of the routes that your doctor might take in his or her pursuit of remission for you.
Medications
Medicine is the obvious first choice for any sufferer of Crohn�s disease. Drugs have been tested for years before gaining approval from the Federal Drug Association (FDA) and most side effects are known. Since there is no real known cause for Crohn�s disease, patients are more than likely to be put on more than one drug at a time in order to titrate a cocktail that works for you. The goals in taking medications for Crohn�s disease include reducing chronic symptoms like pain and diarrhea, helping intestines heal from the damage that the inflammation has caused, and ease the inflammation itself. The following drugs are all used to fight Crohn�s disease:
Steroids
Prednisone:�Also used to treat arthritis, blood disorders, severe allergies, breathing problems, eye problems, and cancer, it is the most well-known corticosteroids. It decreases the immune system�s response time. Is addictive, and the body can also start to resist its effects if taken for too long.
Drugs to Slow Down Your Immune System
Vigilant immune systems are a big cause of Crohn�s disease, although no one has been able to figure out why. Slowing the reaction and response time of the immune system can limit the inflammation damage it does on your GI tract. These drugs include:
Azathioprine: Commonly used to prevent organ rejection in people that have had a kidney transplant. Also used to treat rheumatoid arthritis. It�s an immunosuppressant that weakens the immune system. It can be taken by injection or by mouth.
Cyclosporine:�Used to prevent organ rejection for people who have had a liver, kidney, or heart transplant. Is taken orally once per day.
Mercaptopurine:�This drug is a cancer medication that interferes with the growth of cancer cells, slowing their growth and spread across the body. It is largely used to take on leukemia. It has rough side effects that are fairly similar to Crohn�s disease, including nausea, diarrhea, and loss of appetite, as well as temporary hair loss, mouth sores or pain, and symptoms of liver disease.
Methotrexate:�It is classified as an antimetabolite that works by slowing or stopping the growth of cancer cells and suppressing the immune system. It is often used to stop juvenile rheumatoid arthritis and comes in tablet form. It is a strong medication that requires lots of water consumption to get it out of the kidneys.
TNF Inhibitors
TNF Inhibitors are drugs that help stop inflammation. In addition to Crohn�s disease, they are useful for fighting rheumatoid arthritis, juvenile arthritis, psoriatic arthritis, plaque psoriasis, and ulcerative colitis. The three most frequently used with Crohn�s disease are:
Adalimumab:�Used to reduce pain and spelling in arthritis, it also is used in certain skin conditions. It works by blocking a protein found in the immune system that causes joint swelling and red, scaly patches.
Certolizumab:�Also used to kill tumors, it can defeat a certain type of spine condition in addition to treating Crohn�s to a degree and battling arthritis.
Infliximab:�A champion for chronic plaque psoriasis, it also treats Crohn�s disease and arthritis. It works by blocking the tumor necrosis factor-alpha in the body. It also decreases swelling while weakening the immune system.
Doctors typically start with mild drugs and then move into more strong ones to try and get you into remission. If your Crohn�s disease is atypically severe when you are first diagnosed, the opposite might be true and treatment will start with stronger drugs, drifting toward milder ones once you are in remission.
Surgery
If drugs or steroids aren�t working for you, or if your Crohn�s disease is particularly severe by the time it is first diagnosed, doctors might skip the drug regiment altogether and head straight for surgery. Up to 50% of all people diagnosed with Crohn�s disease will need surgery at some time in their life. The most common surgery will see a doctor remove parts of your intestine where there is too much damage for it to function properly. They then use staples or stitches to reconnect the healthy areas. After this kind of procedure, you will be out of commission for a while, and it might take several months before you feel completely normal again.
After the surgery, you will be fed through a feeding tube with liquid food or even have it injected into your veins to give your bowel the chance to both heal and rest. Once the intestines are determined to be rested and ready to return to active duty, you will be encouraged to eat a low-fiber diet in order to make your body conducive to smaller stools that reduce the risk of bowel blockage. Within a month to four months, you should start seeing the real results of such a procedure.
Understanding Crohn�s Disease in Children
Parents fear any type of health issue for their children, but being diagnosed with a problem, particularly one with no known cure can open up a lot of feelings of panic for both children and their parents. Since most people diagnosed with Crohn�s disease are 30 years old or younger, it stands to reason that it affects many children. And because it can cause malnutrition and other problems that affect growth and development, learning about Crohn�s disease can’t be understated for parents. The best way to talk to your child about having Crohn�s disease is to tell them in a language they can understand that involves the whole family, their doctors, their school, etc. Having a prepared, informed child will make what is to come much easier on them and reduce a lot of their fears of the unknown. If your child is a teenager and more responsible for the food they eat, guiding them in diet and nutrition is a big deal. Honesty is always the best answer for older children on how to manage Crohn�s disease. This is not a temporary condition that has an attainable cure right now. Helping them understand that controlling it will be their responsibility as adults are something that must come into play as well. Clearly, younger children will need more of a hands-on approach. But don�t do everything for them. Unless they are very young, this is a great chance to teach them a gradual taking of responsibility. For younger kids, there are going to be several new events happening that will be either scary or unfamiliar that you can help them transition into. These include:
Taking Medication
For younger children, being sick usually means taking a cough syrup or something similar for a few days and then feeling better. For children with Crohn�s disease, this can elevate to taking pills, getting injections, or sitting during lengthy intravenous transfusions. Taking medication over a long period of time is a new thing for most children. Many will fear it, even something as simple as swallowing pills. Start by introducing them to the medicine � what it looks like, how to take it without chewing it, and explain what the medicine. Let them know that the medicine is the bridge between them feeling bad and having to stay home feeling sick and them feeling good and being able to get out and enjoy some of their favorite pastimes.
It�s also important to remember that children don�t have as good as memories as we do, especially when it comes to remembering what days certain things are taking place. Well into elementary school plenty of kids don�t always know the day of the week or the time of the day without consulting a grownup. That�s why a family calendar with dates marked for medications is a great way to keep everyone on the same page. Make a big deal out of each pill swallowed and appointment completed. Praise is important. When your child feels they are doing the right thing to battle their illness, they will feel better about themselves.
Also, be aware that different medicines do different things and have different side effects. Make your child know that their feelings are important and valid. Ask them how the medicine is making them feel. Better or the same? Explain to them what side effects are and let them know that there are no wrong answers here. If the medicine is making them feel bad, they need to let you know, so you can let the doctor know. Medicine not working is not a sign of defeat, it just means that it�s not the right medicine for them.
Emotional Support
Emotional support is the best medicine for kids diagnosed with Crohn�s disease. It�s not a one-time conversation you have and then move forward with treatment and never talk about it again. Your child is going to have questions as they get older that manifest in many different ways. They will want and need someone to share their thoughts, their fears, and their hopes for the future. The question of �Why me?� is probably going to come up a lot, particularly for children who believe heavily in a particular faith. Some will wonder if the religious figure they worship is punishing them for some wrong they�ve committed. If someone else in the family also suffers from Crohn�s disease, the child might lash out at this relative and blame them for the illness. It is extremely difficult for a child to be different from their peers because of a physical condition, especially when it is one that deals with an already sensitive subject and one that can be rife for bullying at pretty much any age.
If it is too much for your child to take or if you are seeing trouble arise with their schoolwork, friends, or other previously healthy relationships, consider consulting a mental health professional, particularly one who specializes in childhood diseases and how to cope with them. Therapy, medication, or counseling (or some combination of the three) could be just what your child needs to get back on track and learn the process of coping with their illness. Older children and teenagers might need a completely different remedy � space and time alone to rationalize their feelings and decide how best to deal with it. This can include time talking to the doctor alone, without parental involvement. This should not be construed as a panic sign, but a positive that your child is taking charge of his or her own care and wants to discuss with a doctor how to cope with certain conditions. Don�t think you as the parent is in charge of every decision being made. Your child is the one with Crohn�s disease, and that will last a lifetime.
What is a 504 Accommodation Plan?
A 504 accommodation plan, also known as a 504 plan, is a government-approved legally binding document that requires a school to give your child special accommodations due to their disability. It is your job to inform your child�s school of the disability and you�ll be required to give proof of it � a simple doctor�s note will do. The plan covers your child having an unexpected flare-up of Crohn�s disease at school or if they are hospitalized and miss time. Accommodations will vary from child to child, but you must advocate for their rights at all times to ensure the school staff knows exactly what procedures must be followed, particularly in the event of a flare-up. Flare-ups can make anyone feel extremely uncomfortable as it can cause diarrhea or irregular bowel movements. In a school setting, this can be scary, humiliating, and embarrassing for a child, so all precautions must be in place, such as your child having the right to visit the bathroom at any time during the school day without being questioned, or bringing another pair of clothes to school in case of an accident. The school nurse in particular should be made aware of the situation, as she will usually be the most knowledgeable of Crohn�s disease and the best suited to help your child should they have an accident or need help during the day. If your child misses a lot of school for doctor�s appointments or hospital stays, the 504 plan should include provisions to allow them extra time to do assignments or things like take-home tests to give them the time and atmosphere to perform their best.
How Can You Handle Your Job When Your Child Has Crohn�s Disease?
Most jobs these days make all sorts of allowances for employees when it comes to paid time off (PTO) in the form of sick days and personal days. Having a child with Crohn�s disease can seem like a very personal issue and one that you don�t necessarily want to share with a lot of people, but it is necessary to inform your job, especially our human resources (HR) representative of the situation so you can best handle your responsibilities at work while also being there for your child. Your job will most likely be sympathetic to your child�s needs and do its best to accommodate you when you need to stay home with him or her or if you need to take them to the hospital. However, try and let your job know about planned hospital visits or procedures as far in advance as possible to give them the best chance to schedule someone to do your assigned tasks. If your job allows you to work remotely, try and see if you can make the accommodation for days that you might need to stay home with your child. Do everything possible to do your work, even if it is not at the precise date and time as everyone else in the office. Share your child�s schedule for surgery, blood draws, imaging, or any other scheduled appointment with your supervisor and your HR representative so they can appropriately deduct the time missed from your PTO, sick days, or family leave days, however, your company works it out. The more information that you can give your job about your schedule, the more likely they are to work with you. A company cannot legally fire you for a child�s illness, but if you do not communicate with them on the amount of time you take off, or if you are only informing them of time you need off with very little or no notice, you could find yourself getting dismissed for being unable to perform your duties and an unwillingness to keep an open dialogue.
Children�s Health Insurance and Crohn�s Disease
Your child is covered by either you or your spouse�s health insurance, but you�ll need more information than that to make sure that your child gets the best care possible. Once a diagnosis has been made by your child�s doctor, set aside some time to call your insurance company, explain the situation, and get all of your questions answered. Your insurance plan will have operating procedures based on the coverage plan you have preselected. These will include a deductible that you will likely have to meet before all expenses are paid for, co-pays for your child�s visits to the doctor, and possibly a number of treatments that are covered as part of the plan. During this meeting, you should also ask questions about prescription medications as well as which brands and drugs are covered under your plan. If certain drugs are too expensive, you can contact drug companies or look for discounts and coupons online. For health issues like Crohn�s disease, manufacturers and discount organizations often work hard to make otherwise unattainable drugs more affordable for suffering patients.
Crohn’s disease is an inflammatory bowel disease or IBD. Although healthcare professionals today still don’t know the true cause of this health issue, several doctors and researchers believe that factors like poor diet and stress can aggravate the symptoms associated with this health issue. Common symptoms associated with Crohn’s disease can include pain and inflammation. Proper diagnosis and treatment for this health issue are essential because it can lead to a variety of complications, including joint pain and arthritis, among other health issues, if left untreated. Diet and lifestyle modifications, stress management, medication, and surgery, can ultimately help improve Crohn’s disease. For people following several of the previously mentioned treatment options, chiropractic care and physical therapy can also help relieve joint pain and arthritis, among other health issues, associated with inflammation. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas*& New Mexico*�
Our brain is constantly working to help us make decisions, speak, read, and perform many other important functions. It’s also responsible for several involuntary processes, including breathing, regulating body temperature, and secreting hormones. The brain needs a consistent supply of energy in order to perform these essential functions. It mainly uses glucose as fuel for energy, however, does the brain really need glucose from carbohydrates to function properly?
What Happens When You Don’t Eat Carbohydrates?
According to healthcare professionals, the brain needs between 110 to 145 grams of glucose per day to function properly. Most people who follow a high-carb diet provide their brains with an abundant supply of glucose. However, what happens when you eat less than 110 grams of carbohydrates per day or even no carbs at all? Does your brain starve? Absolutely not! Our muscles and liver store glucose in the form of glycogen, a polysaccharide of glucose.
When you don’t eat carbs, glycogen in the liver is broken down into glucose and released into the bloodstream to prevent low blood glucose levels. While more glycogen is stored in the muscles than in the liver, it stays in the muscles to meet their demand for energy and it can’t be broken down and released into the bloodstream to prevent low blood glucose levels. After about 24 to 48 hours without eating carbohydrates, glycogen in the liver is depleted and insulin decreases.
The liver will then produce ketones, water-soluble compounds produced by the breakdown of fatty acids. Ketones are produced from the fats you eat or the movement of stored body fat. Ketones can penetrate the blood-brain barrier (BBB) and enter the bloodstream in order to reach the brain and provide additional energy. This ultimately means that ketones can also be used as fuel for energy when our body is running low on glucose from carbohydrates.
Can Your Brain Use Ketones Alone for Energy?
Our brain always needs some glucose for energy. However, healthcare professionals have shown that for several people following a ketogenic diet, ketones can be used to meet up to 70 percent of the brain�s energy needs. As for the rest of the brain�s energy needs, your liver can produce the glucose it needs through a process known as gluconeogenesis. Thus, the liver can meet the brain’s energy needs through stored glucose, the production of ketones, or gluconeogenesis.
Glucose Alone vs Glucose and Ketones for Energy
If you follow a moderate-carb to a high-carb diet, your brain may not be properly adapted to use ketones as fuel for energy. Therefore, glucose will be the main source of energy for your brain. However, when your body has adapted to following a low-carb or carb-free diet, the brain can easily use ketones to meet the brain’s energy needs and the liver can make as much glucose as it needs to meet the rest of the brain’s energy needs in order to function properly.
What are the Low-Carb and Ketogenic Diet?
While there is a lot of similarities between the low-carb and ketogenic diet, there are also several important differences. The differences between the low-carb and the ketogenic diet may include but are not limited to the following:
Ketogenic Diet
Carbohydrates are limited to 50 grams or less per day.
Protein is generally limited or restricted.
The main goal is to increase the production of ketones.
Low-Carb Diet
Carbohydrates can vary from 25 to 150 grams per day.
Protein is typically not limited or restricted.
Production of etones may or may not increase.
In conclusion, eating carbohydrates to use as fuel for the brain’s energy needs is an option, not a requirement. It�s true that the brain can�t depend on ketones alone as it always needs some glucose as well. It’s important to understand that your brain isn�t in any danger if you follow a low-carb or a ketogenic diet. However, before following any particular diet, always make sure to talk to a healthcare professional to determine if these nutritional guidelines are right for you.
For information regarding the effects of carbohydrates on the brain, please review the following article:
Our brain is constantly working to perform many important functions. The brain needs a consistent supply of energy in order to perform these essential functions and while it mainly uses glucose as fuel for energy,� the brain doesn’t really need glucose from carbohydrates to function properly. Glycogen in the liver is broken down into glucose. The liver will then produce ketones, water-soluble compounds produced by the breakdown of fatty acids. Ketones are produced from the fats you eat or the movement of stored body fat. Ketones can penetrate the blood-brain barrier (BBB) and provide additional energy for the brain. However, our brain always needs some glucose for energy. Your liver can also produce the glucose it needs through a process known as gluconeogenesis. Thus, the liver can meet the brain’s energy needs through stored glucose, the production of ketones, or gluconeogenesis. A low-carb or a ketogenic diet can provide a variety of benefits. Always make sure to talk to a healthcare professional to determine if these nutritional guidelines are right for you.�- Dr. Alex Jimenez D.C., C.C.S.T. Insight
Zesty Beet Juice
Servings: 1 Cook time: 5-10 minutes
� 1 grapefruit, peeled and sliced
� 1 apple, washed and sliced
� 1 whole beet, and leaves if you have them, washed and sliced
� 1-inch knob of ginger, rinsed, peeled and chopped
Juice all ingredients in a high-quality juicer. Best served immediately.
Just one carrot gives you all of your daily vitamin A intake
Yes, eating just one boiled 80g (2�oz) carrot gives you enough beta carotene for your body to produce 1,480 micrograms (mcg) of vitamin A (necessary for skin cell renewal). That’s more than the recommended daily intake of vitamin A in the United States, which is about 900mcg. It’s best to eat carrots cooked, as this softens the cell walls allowing more beta carotene to be absorbed. Adding healthier foods into your diet is a great way to improve your overall health.
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas*& New Mexico*�
Curated by Dr. Alex Jimenez D.C., C.C.S.T.
References:
Spritzler, Franziska. �Food for Thought: Does the Brain Need Carbs?� Diet Doctor, Diet Doctor Media, 17 Jan. 2019, www.dietdoctor.com/low-carb/does-the-brain-need-carbs.
Spritzler, Franziska. �How Low-Carb and Ketogenic Diets Boost Brain Health.� Healthline, Healthline Media, 26 Mar. 2016, www.healthline.com/nutrition/low-carb-ketogenic-diet-brain#section1.
Dowden, Angela. �Coffee Is a Fruit and Other Unbelievably True Food Facts.� MSN Lifestyle, 4 June 2020, www.msn.com/en-us/foodanddrink/did-you-know/coffee-is-a-fruit-and-other-unbelievably-true-food-facts/ss-BB152Q5q?li=BBnb7Kz&ocid=mailsignout#image=24.
Folate is a B vitamin naturally found in a variety of foods. The body can’t produce folate, that’s why it’s important to get it from folate-rich foods. Folate is naturally found in various plant and animal foods, including citrus fruits, avocado, spinach, kale, broccoli, eggs, and beef liver. Folate is also added to foods, such as bread, flours, and cereals, in the form of folic acid or the synthetic, water-soluble version of folate. Folate and folic acid have different effects on the body.
Our body utilizes folate for a variety of essential functions, including cell division, development of red blood cells, conversion of homocysteine to methionine, an amino acid used for protein synthesis, production of SAMe, and DNA methylation. Folic acid is also important for various metabolic processes. Folate deficiency has ultimately been associated with a variety of health issues, such as the increased risk of heart disease, birth defects, megaloblastic anemia, and cancer.
Daily Intake of Folate and Folic Acid
Our body stores between 10 to 30 mg of folate, most of which is stored in your liver while the remaining amount is stored in your blood and tissues. Normal blood folate levels range from 5 to 15 ng/mL. The main form of folate in the bloodstream is known as 5-methyltetrahydrofolate. Daily intake of this essential nutrient is different for people of different ages. The recommended daily allowance of folate for infants, children, teens, adults, and pregnant women are as follows:
0 to 6 months: 65 mcg
7 to 12 months: 80 mcg
1 to 3 years: 150 mcg
4 to 8 years: 200 mcg
9 to 13 years: 300 mcg
over 14 years: 400 mcg
during pregnancy: 600 mcg
during lactation: 500 mcg
Folic acid supplements play an important role in making sure that people who are in greater need of folate are getting enough of their daily intake. Increasing the daily intake of folate-rich foods is also important because these foods generally offer plenty of other nutrients that all act together to support overall health. Recommended folate daily intake increases during pregnancy and breastfeeding to promote rapid growth and help prevent neural tube defects in the fetus.
Folic acid is available in dietary supplements and fortified foods, including bread, flours, cereals, and several types of grains. It is also added to B-complex vitamins. Folate is also naturally found in a variety of foods, including:
oranges
orange juice
grapefruit
bananas
cantaloupe
papaya
canned tomato juice
avocado
boiled spinach
mustard greens
lettuce
asparagus
Brussels sprouts
broccoli
green peas
black-eyed peas
dry-roasted peanuts
kidney beans
eggs
Dungeness crab
beef liver
Uses of Folate and Folic Acid
Both folate and folic acid are frequently utilized for a variety of reasons. Although folate and folic acid supplements are generally used to treat similar health issues, they do offer different effects in the body and, therefore, it may affect our overall health in different ways. Moreover, getting the proper daily intake of folate and folic acid can improve overall health. The following are several of the most common uses of folate and folic acid supplements, including:
folate deficiency
inflammation
diabetes
brain health
heart disease
kidney disease
mental health issues
fertility problems
birth defects and pregnancy complications
For information regarding the importance of folate and folic acid, please review the following article:
Folate is a B vitamin that is naturally found in many different types of food. Because we can’t produce folate, it’s important to get it from foods that are high in folate. Various folate-rich foods include citrus fruits, avocado, spinach, kale, broccoli, eggs, and beef liver. Folate is also added to foods like bread, flours, and cereals, in the form of folic acid, the synthetic version of this essential nutrient. Folate and folic acid have different effects on the body. Our body uses folate for many important functions, including cell division, development of red blood cells, conversion of homocysteine to methionine, an amino acid used for protein synthesis, production of SAMe, and DNA methylation. Folic acid is also essential for many metabolic processes. Folate deficiency has ultimately been associated with a variety of health issues, such as heart disease, birth defects, megaloblastic anemia, and even cancer. Daily intake of this essential nutrient is different for people of different ages. Furthermore, folate is also naturally found in a variety of foods, such as bananas, avocado, boiled spinach, and eggs. Both folate and folic acid supplements have a variety of uses and they can help improve various health issues, including inflammation, diabetes, heart disease, birth defects, and pregnancy complications. Adding healthy foods to a smoothie is a fast and easy way to get your daily intake of folate. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
Ginger Greens Juice
Servings: 1 Cook time: 5-10 minutes
� 1 cup pineapple cubes
� 1 apples, sliced
� 1-inch knob of ginger, rinsed, peeled, and chopped
� 3 cups kale, rinsed, and roughly chopped or ripped
� 5 cups Swiss chard, rinsed, and roughly chopped or ripped
Juice all ingredients in a high-quality juicer. Best served immediately.
Eating cholesterol-rich foods doesn�t increase your cholesterol
According to research studies, eating foods with HDL cholesterol or “good” cholesterol doesn’t increase your overall blood cholesterol levels. When you eat healthy cholesterol-rich foods, such as prawns and eggs, your blood cholesterol levels decrease, so your blood cholesterol levels stay balanced, or they’re only raised minimally. It’s actually saturated fats that you have to look out for when it comes to high blood cholesterol levels. Simply choose healthier food options.
The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas*& New Mexico*�
Curated by Dr. Alex Jimenez D.C., C.C.S.T.
References:
Kubala, Jillian. �Folic Acid: Everything You Need to Know.� Healthline, Healthline Media, 18 May 2020, www.healthline.com/nutrition/folic-acid#What-is-folic-acid?
Ware, Megan. �Folate: Health Benefits and Recommended Intake.� Medical News Today, MediLexicon International, 26 June 2018, www.medicalnewstoday.com/articles/287677#recommended-intake.
Felman, Adam. �Folic Acid: Importance, Deficiencies, and Side Effects.� Medical News Today, MediLexicon International, 11 Mar. 2020, www.medicalnewstoday.com/articles/219853#natural-sources.
Berg, M J. �The Importance of Folic Acid.� The Journal of Gender-Specific Medicine: JGSM: the Official Journal of the Partnership for Women’s Health at Columbia, U.S. National Library of Medicine, June 1999, pubmed.ncbi.nlm.nih.gov/11252849/.
Dowden, Angela. �Coffee Is a Fruit and Other Unbelievably True Food Facts.� MSN Lifestyle, 4 June 2020, www.msn.com/en-us/foodanddrink/did-you-know/coffee-is-a-fruit-and-other-unbelievably-true-food-facts/ss-BB152Q5q?li=BBnb7Kz&ocid=mailsignout#image=23.
IFM's Find A Practitioner tool is the largest referral network in Functional Medicine, created to help patients locate Functional Medicine practitioners anywhere in the world. IFM Certified Practitioners are listed first in the search results, given their extensive education in Functional Medicine
