Archive for August, 2009

Understanding Arthritis

August 26th, 2009

What is arthri­tis? What causes arthritis?

Arthri­tis is a joint dis­or­der fea­tur­ing inflam­ma­tion. A joint is an area of the body where two dif­fer­ent bones meet. A joint func­tions to move the body parts con­nected by its bones. Arthri­tis lit­er­ally means inflam­ma­tion of one or more joints.

Arthri­tis is fre­quently accom­pa­nied by joint pain. Joint pain is referred to as arthralgia.

There are many types of arthri­tis (over 100 and grow­ing). The types range from those related to wear and tear of car­ti­lage (such as osteoarthri­tis) to those asso­ci­ated with inflam­ma­tion result­ing from an over­ac­tive immune sys­tem (such as rheuma­toid arthri­tis). Together, the many types of arthri­tis make up the most com­mon chronic ill­ness in the United States.

The causes of arthri­tis depend on the form of arthri­tis. Causes include injury (lead­ing to osteoarthri­tis), meta­bolic abnor­mal­i­ties (such as gout and pseudo­gout), hered­i­tary fac­tors, infec­tions, and unclear rea­sons (such as rheuma­toid arthri­tis and sys­temic lupus erythematosus).

Arthri­tis is clas­si­fied as one of the rheumatic dis­eases. These are con­di­tions that are dif­fer­ent indi­vid­ual ill­nesses, with dif­fer­ing fea­tures, treat­ments, com­pli­ca­tions, and prog­noses. They are sim­i­lar in that they have a ten­dency to affect the joints, mus­cles, lig­a­ments, car­ti­lage, and ten­dons, and many have the poten­tial to affect other inter­nal body areas.

What are symp­toms of arthritis?

Symp­toms of arthri­tis include pain and lim­ited func­tion of joints. Inflam­ma­tion of the joints from arthri­tis is char­ac­ter­ized by joint stiff­ness, swelling, red­ness, and warmth. Ten­der­ness of the inflamed joint can be present.

Many of the forms of arthri­tis, because they are rheumatic dis­eases, can cause symp­toms affect­ing var­i­ous organs of the body that do not directly involve the joints. There­fore, symp­toms in some patients with cer­tain forms of arthri­tis can also include fever, gland swelling (lymph node), weight loss, fatigue, feel­ing unwell, and even symp­toms from abnor­mal­i­ties of organs such as the lungs, heart, or kidneys.

Who is affected by arthritis?

Arthri­tis suf­fer­ers include men and women, chil­dren and adults. Approx­i­mately 350 mil­lion peo­ple world­wide have arthri­tis. Nearly 40 mil­lion peo­ple in the United States are affected by arthri­tis, includ­ing over a quar­ter mil­lion children!

More than 27 mil­lion Amer­i­cans have osteoarthri­tis. Approx­i­mately 1.3 mil­lion Amer­i­cans suf­fer from rheuma­toid arthritis.

More than half of those with arthri­tis are under 65 years of age. Nearly 60% of Amer­i­cans with arthri­tis are women.

How is arthri­tis diag­nosed, and why is a diag­no­sis important?

The first step in the diag­no­sis of arthri­tis is a meet­ing between the doc­tor and the patient. The doc­tor will review the his­tory of symp­toms, exam­ine the joints for inflam­ma­tion and defor­mity, as well as ask ques­tions about or exam­ine other parts of the body for inflam­ma­tion or signs of dis­eases that can affect other body areas. Fur­ther­more, cer­tain blood, urine, joint fluid, and/or X-ray tests might be ordered. The diag­no­sis will be based on the pat­tern of symp­toms, the dis­tri­b­u­tion of the inflamed joints, and any blood and X-ray find­ings. Sev­eral vis­its may be nec­es­sary before the doc­tor can be cer­tain of the diag­no­sis. A doc­tor with spe­cial train­ing in arthri­tis and related dis­eases is called a rheuma­tol­o­gist (see below).

Many forms of arthri­tis are more of an annoy­ance than seri­ous. How­ever, mil­lions of patients suf­fer daily with pain and dis­abil­ity from arthri­tis or its complications.

Ear­lier and accu­rate diag­no­sis can help to pre­vent irre­versible dam­age and dis­abil­ity. Prop­erly guided pro­grams of exer­cise and rest, med­ica­tions, phys­i­cal ther­apy, and surgery options can ide­al­ize long-term out­comes for arthri­tis patients.

It should be noted that both before and espe­cially after the diag­no­sis of arthri­tis, com­mu­ni­ca­tion with the treat­ing doc­tor is essen­tial for opti­mal health. This is impor­tant from the stand­point of the doc­tor, so that he/she can be aware of the vagaries of the patient’s symp­toms as well as their tol­er­ance of and accep­tance of treat­ments. It is impor­tant from the stand­point of patients, so that they can be assured that they have an under­stand­ing of the diag­no­sis and how the con­di­tion does and might affect them. It is also cru­cial for the safe use of medications.

How is arthri­tis treated?

The treat­ment of arthri­tis is very depen­dent on the pre­cise type of arthri­tis present. An accu­rate diag­no­sis increases the chances for suc­cess­ful treat­ment. Treat­ments avail­able include phys­i­cal ther­apy, splint­ing, cold pack appli­ca­tion, paraf­fin wax dips, anti inflam­ma­tion med­ica­tions, immune-altering med­ica­tions, and sur­gi­cal operations.

What is a rheumatologist?

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

Rheuma­tol­o­gists have spe­cial inter­ests in unex­plained rash, fever, arthri­tis, ane­mia, weak­ness, weight loss, fatigue, joint or mus­cle pain, autoim­mune dis­ease, and anorexia. They often serve as con­sul­tants, act­ing like med­ical detec­tives at the request of other doctors.

Rheuma­tol­o­gists have par­tic­u­lar skills in the eval­u­a­tion of the over 100 forms of arthri­tis and have spe­cial inter­ests in rheuma­toid arthri­tis, spondyli­tis, pso­ri­atic arthri­tis, sys­temic lupus ery­the­mato­sus, antiphos­pho­lipid syn­drome, Still’s dis­ease, der­mato­myosi­tis, Sjogren’s syn­drome, vas­culi­tis, scle­ro­derma, mixed con­nec­tive tis­sue dis­ease, sar­coido­sis, Lyme dis­ease, osteomyelitis, osteoarthri­tis, back pain, gout, pseudo­gout, relaps­ing poly­chon­dri­tis, Henoch-Schonlein pur­pura, serum sick­ness, reac­tive arthri­tis, Kawasaki dis­ease, fibromyal­gia, ery­throme­lal­gia, Raynaud’s dis­ease, grow­ing pains, iri­tis, osteo­poro­sis, reflex sym­pa­thetic dys­tro­phy, and others.

Clas­si­cal adult rheuma­tol­ogy train­ing includes four years of med­ical school, one year of intern­ship in inter­nal med­i­cine, two years of internal-medicine res­i­dency, and two years of rheuma­tol­ogy fel­low­ship. There is a sub­spe­cialty board for rheuma­tol­ogy cer­ti­fi­ca­tion, offered by the Amer­i­can Board of Inter­nal Med­i­cine, which can pro­vide board cer­ti­fi­ca­tion to approved rheumatologists.

Pedi­atric rheuma­tol­o­gists are physi­cians who spe­cial­ize in pro­vid­ing com­pre­hen­sive care to chil­dren (as well as their fam­i­lies) with rheumatic dis­eases, espe­cially arthritis.

Pedi­atric rheuma­tol­o­gists are pedi­a­tri­cians who have com­pleted an addi­tional two to three years of spe­cial­ized train­ing in pedi­atric rheuma­tol­ogy and are usu­ally board-certified in pedi­atric rheumatology.

Arthri­tis At A Glance

* Arthri­tis is inflam­ma­tion of one or more joints.
* Symp­toms of arthri­tis include pain and lim­ited func­tion of joints.
* Arthri­tis suf­fer­ers include men and women, chil­dren and adults.
* A rheuma­tol­o­gist is a med­ical arthri­tis expert.
* Ear­lier and accu­rate diag­no­sis can help to pre­vent irre­versible dam­age and disability.

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Understanding Your Knee

August 26th, 2009

How is the knee designed, and what is its function?

knee_jointThe knee is a joint that has three com­part­ments. The thigh bone (femur) meets the large shin bone (tibia) form­ing the main knee joint. This joint has an inner (medial) and an outer (lat­eral) com­part­ment. The kneecap (patella) joins the femur to form a third com­part­ment, called the patellofemoral joint.

The knee joint is sur­rounded by a joint cap­sule with lig­a­ments strap­ping the inside and out­side of the joint (col­lat­eral lig­a­ments) as well as cross­ing within the joint (cru­ci­ate lig­a­ments). These lig­a­ments pro­vide sta­bil­ity and strength to the knee joint.

The menis­cus is a thick­ened car­ti­lage pad between the two joints formed by the femur and tibia. The menis­cus acts as a smooth sur­face for motion and absorbs the load of the body above the knee when stand­ing. The knee joint is sur­rounded by fluid-filled sacs called bur­sae, which serve as glid­ing sur­faces that reduce fric­tion of the ten­dons. Below the kneecap, there is a large ten­don (patel­lar ten­don) which attaches to the front of the tibia bone. There are large blood ves­sels pass­ing through the area behind the knee (referred to as the popliteal space). The large mus­cles of the thigh move the knee. In the front of the thigh, the quadri­ceps mus­cles extend the knee joint. In the back of the thigh, the ham­string mus­cles flex the knee. The knee also rotates slightly under guid­ance of spe­cific mus­cles of the thigh.

The knee func­tions to allow move­ment of the leg and is crit­i­cal to nor­mal walk­ing. The knee flexes nor­mally to a max­i­mum of 135 degrees and extends to 0 degrees. The bur­sae, or fluid-filled sacs, serve as glid­ing sur­faces for the ten­dons to reduce the force of fric­tion as these ten­dons move. The knee is a weight-bearing joint. Each menis­cus serves to evenly load the sur­face dur­ing weight-bearing and also aids in dis­burs­ing joint fluid for joint lubrication.

What injuries can cause knee pain, and what other symp­toms may accom­pany knee pain?

Injury can affect any of the lig­a­ments, bur­sae, or ten­dons sur­round­ing the knee joint. Injury can also affect the lig­a­ments, car­ti­lage, menisci (plural for menis­cus), and bones form­ing the joint. The com­plex­ity of the design of the knee joint and the fact that it is an active weight-bearing joint are fac­tors in mak­ing the knee one of the most com­monly injured joints.

Lig­a­ment injury

Trauma can cause injury to the lig­a­ments on the inner por­tion of the knee (medial col­lat­eral lig­a­ment), the outer por­tion of the knee (lat­eral col­lat­eral lig­a­ment), or within the knee (cru­ci­ate lig­a­ments). Injuries to these areas are noticed as imme­di­ate pain but are some­times dif­fi­cult to local­ize. Usu­ally, a col­lat­eral lig­a­ment injury is felt on the inner or outer por­tions of the knee. A col­lat­eral lig­a­ment injury is often asso­ci­ated with local ten­der­ness over the area of the lig­a­ment involved. A cru­ci­ate lig­a­ment injury is felt deep within the knee. It is some­times noticed with a “pop­ping” sen­sa­tion with the ini­tial trauma. A lig­a­ment injury to the knee is usu­ally painful at rest and may be swollen and warm. The pain is usu­ally wors­ened by bend­ing the knee, putting weight on the knee, or walk­ing. The sever­ity of the injury can vary from mild (minor stretch­ing or tear­ing of the lig­a­ment fibers, such as a low grade sprain) to severe (com­plete tear of the lig­a­ment fibers). Patients can have more than one area injured in a sin­gle trau­matic event.

Lig­a­ment injuries are ini­tially treated with ice packs and immo­bi­liza­tion, with rest and ele­va­tion. It is gen­er­ally rec­om­mended to avoid bear­ing weight on the injured joint, and crutches may be required for walk­ing. Some patients are placed in splints or braces to immo­bi­lize the joint to decrease pain and pro­mote heal­ing. Arthro­scopic or open surgery may be nec­es­sary to repair severe injuries.

Sur­gi­cal repair of lig­a­ments can involve sutur­ing alone, graft­ing, and syn­thetic graft repair. These pro­ce­dures can be done by either open knee surgery or arthro­scopic surgery (described in the sec­tion below). The deci­sion to per­form var­i­ous types of surgery depends on the level of dam­age to the lig­a­ments and the activ­ity expec­ta­tions of the patient. Many repairs can now be done arthro­scop­i­cally. How­ever, cer­tain severe injuries will require an open sur­gi­cal repair. Recon­struc­tion pro­ce­dures for cru­ci­ate lig­a­ments are increas­ingly suc­cess­ful with cur­rent sur­gi­cal techniques.

Menis­cus tears

The menis­cus can be torn with the shear­ing forces of rota­tion that are applied to the knee dur­ing sharp, rapid motions. This is espe­cially com­mon in sports requir­ing reac­tion body move­ments. There is a higher inci­dence with aging and degen­er­a­tion of the under­ly­ing car­ti­lage. More than one tear can be present in an indi­vid­ual menis­cus. The patient with a menis­cal tear may have a rapid onset of a pop­ping sen­sa­tion with a cer­tain activ­ity or move­ment of the knee. Occa­sion­ally, it is asso­ci­ated with swelling and warmth in the knee. It is often asso­ci­ated with lock­ing or an unsta­ble sen­sa­tion in the knee joint. The doc­tor can per­form cer­tain maneu­vers while exam­in­ing the knee which might pro­vide fur­ther clues to the pres­ence of a menis­cal tear.

Rou­tine X-rays, while they do not reveal a menis­cal tear, can be used to exclude other prob­lems of the knee joint. The menis­cal tear can be diag­nosed in one of three ways: arthroscopy, arthrog­ra­phy, or an MRI. Arthroscopy is a sur­gi­cal tech­nique by which a small diam­e­ter video cam­era is inserted through tiny inci­sions on the sides of the knee for the pur­poses of exam­in­ing and repair­ing inter­nal knee joint prob­lems. Tiny instru­ments can be used dur­ing arthroscopy to repair the torn meniscus.

Arthrog­ra­phy is a radi­ol­ogy tech­nique whereby a con­trast liq­uid is directly injected into the knee joint and inter­nal struc­tures of the knee joint thereby become vis­i­ble on X-ray film. An MRI scan is another radi­ol­ogy tech­nique whereby mag­netic fields and a com­puter com­bine to pro­duce two– or three-dimensional images of the inter­nal struc­tures of the body. It does not use X-rays and can give accu­rate infor­ma­tion about the inter­nal struc­tures of the knee when con­sid­er­ing a sur­gi­cal inter­ven­tion. Menis­cal tears are often vis­i­ble using an MRI scan­ner. MRI scans have largely replaced arthrog­ra­phy in diag­nos­ing menis­cal tears of the knee. Menis­cal tears are gen­er­ally repaired arthroscopically.

Ten­dini­tis

Ten­dini­tis of the knee occurs in the front of the knee below the kneecap at the patel­lar ten­don (patel­lar ten­dini­tis) or in the back of the knee at the popliteal ten­don (popliteal ten­dini­tis). Ten­dini­tis is an inflam­ma­tion of the ten­don, which is often pro­duced by a strain event, such as jump­ing. Patel­lar ten­dini­tis, there­fore, also has the name “jumper’s knee.” Ten­dini­tis is diag­nosed based on the pres­ence of pain and ten­der­ness local­ized to the ten­don. It is treated with a com­bi­na­tion of ice packs, immo­bi­liza­tion with a knee brace as needed, rest, and anti­in­flam­ma­tory med­ica­tions. Grad­u­ally, exer­cise pro­grams can reha­bil­i­tate the tis­sues in and around the involved ten­don. Cor­ti­sone injec­tions, which can be given for ten­dini­tis else­where, are gen­er­ally avoided in patel­lar ten­dini­tis because there are reports of risk of ten­don rup­ture as a result of cor­ti­cos­teroids in this area. In severe cases, surgery can be required. A rup­ture of the ten­don below or above the kneecap can occur. When it does, there may be bleed­ing within the knee joint and extreme pain with any knee move­ment. Sur­gi­cal repair of the rup­tured ten­don is often necessary.

Frac­tures

With severe knee trauma, such as motor vehi­cle acci­dents and impact trau­mas, bone break­age (frac­ture) of any of the three bones of the knee can occur. Bone frac­tures within the knee joint can be seri­ous and can require sur­gi­cal repair as well as immo­bi­liza­tion with cast­ing or other supports.

What are dis­eases and con­di­tions that can cause knee pain, and how are they treated?

Pain can occur in the knee from dis­eases or con­di­tions that involve the knee joint, the soft tis­sues and bones sur­round­ing the knee, or the nerves that sup­ply sen­sa­tion to the knee area. In fact, the knee joint is the most com­monly involved joint in rheumatic dis­eases, immune dis­eases that affect var­i­ous tis­sues of the body includ­ing the joints to cause arthritis.

Arthri­tis is inflam­ma­tion within a joint. The causes of knee joint inflam­ma­tion range from non­in­flam­ma­tory types of arthri­tis such as osteoarthri­tis, which is a degen­er­a­tion of the car­ti­lage of the knee, to inflam­ma­tory types of arthri­tis (such as rheuma­toid arthri­tis or gout). Treat­ment of the arthri­tis is directed accord­ing to the nature of the spe­cific type of arthri­tis. For more infor­ma­tion on arthri­tis, please read the fol­low­ing arti­cles: Pso­ri­atic Arthri­tis and Reac­tive Arthritis.

Swelling of the knee joint from arthri­tis can lead to a local­ized col­lec­tion of fluid accu­mu­lat­ing in a cyst behind the knee. This is referred to as a Baker cyst and is a com­mon cause of pain at the back of the knee.

Infec­tions of the bone or joint can rarely be a seri­ous cause of knee pain and have asso­ci­ated signs of infec­tion includ­ing fever, extreme heat, warmth of the joint, chills of the body, and may be asso­ci­ated with punc­ture wounds in the area around the knee.

Tumors involv­ing the joint are extremely rare. They can cause prob­lems with local pain.

The col­lat­eral lig­a­ment on the inside of the knee joint can become cal­ci­fied and is referred to as Pellegrini-Stieda syn­drome. With this con­di­tion, the knee can become inflamed and can be treated con­ser­v­a­tively with ice packs, immo­bi­liza­tion, and rest. Infre­quently, it requires a local injec­tion of corticosteroids.

Chon­dro­ma­la­cia refers to a soft­en­ing of the car­ti­lage under the kneecap (patella). It is a com­mon cause of deep knee pain and stiff­ness in younger women and can be asso­ci­ated with pain and stiff­ness after pro­longed sit­ting and climb­ing stairs or hills. While treat­ment with anti­in­flam­ma­tory med­ica­tions, ice packs, and rest can help, long-term relief is best achieved by strength­en­ing exer­cises for the quadri­ceps mus­cles of the front of the thigh.

Bur­si­tis of the knee com­monly occurs on the inside of the knee (anser­ine bur­si­tis) and the front of the kneecap (patel­lar bur­si­tis, or “housemaid’s knee”). Bur­si­tis is gen­er­ally treated with ice packs, immo­bi­liza­tion, and anti­in­flam­ma­tory med­ica­tions such as ibupro­fen (Advil, Motrin) or aspirin and may require local injec­tions of cor­ti­cos­teroids (cor­ti­sone med­ica­tion) as well as exer­cise ther­apy to develop the mus­cu­la­ture of the front of the thigh.
Knee Pain At A Glance

* The knee joint has three com­part­ments.
* Causes of knee pain include injury, degen­er­a­tion, arthri­tis, infre­quently infec­tion, and rarely bone tumors.
* Lig­a­ments within the knee (cru­ci­ate lig­a­ments) and on the inner and outer sides of the knee (col­lat­eral lig­a­ments) sta­bi­lize the joint.
* Sur­gi­cal repair of lig­a­ment injury can involve sutur­ing, graft­ing, and syn­thetic graft repair.
* Rou­tine X-rays do not reveal menis­cus tears but can be used to exclude other prob­lems of the bones and other tis­sues.
* The knee joint is the most com­monly involved joint in rheumatic dis­eases, which are immune dis­eases that affect var­i­ous tis­sues of the body, includ­ing the joints, to cause arthritis.

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Wrist Pain, What happen?

August 19th, 2009

b_15_4_3bWrist pain is an extremely com­mon com­plaint, and there are many com­mon causes of this prob­lem. It is impor­tant to make an accu­rate diag­no­sis of the cause of your symp­toms so that appro­pri­ate treat­ment can be directed at the cause. If you have wrist pain, some com­mon causes include:

* Ten­donitis
Ten­donitis is a com­mon prob­lem that can cause wrist pain and swelling. Wrist ten­donitis is due to inflam­ma­tion of the ten­don sheath. Treat­ment of wrist pain caused by ten­donitis usu­ally does not require surgery.

* Sprain
Wrist sprains are com­mon injuries to the lig­a­ments around the wrist joint. Sprains can cause prob­lems by lim­it­ing the use of our hands.

* Carpal Tun­nel Syn­drome
Carpal tun­nel syn­drome is the con­di­tion that results from dys­func­tion of one of the nerves in the wrist. In carpal tun­nel syn­drome the median nerve is com­pressed, or pinched off, as it passes through the wrist joint.

* Arthri­tis
Arthri­tis is a prob­lem that can cause wrist pain and dif­fi­culty per­form­ing nor­mal activ­i­ties. There are sev­eral causes of arthri­tis, and for­tu­nately there are a num­ber of treat­ments for wrist arthritis.

* Gan­glion Cyst
A gan­glion cyst is a swelling that usu­ally occurs over the back of the hand or wrist. These are benign, fluid-filled cap­sules. Gan­glion cysts are not can­cer­ous, will not spread, and while they may grow in size, they will not spread to other parts of your body.

* Frac­tures
A wrist frac­ture is a com­mon ortho­pe­dic injury. Patients who sus­tain a bro­ken wrist may be treated in a cast, or they may need surgery for the fracture.

When do you need to call your doc­tor about your wrist pain?
If you are unsure of the cause of your wrist pain, or if you do not know the spe­cific treat­ment rec­om­men­da­tions for your con­di­tion, you should seek med­ical atten­tion. Treat­ment of these con­di­tions must be directed at the spe­cific cause of your prob­lem. Some signs that you should be seen by a doc­tor include:

o Inabil­ity to carry objects or use the arm
o Injury that causes defor­mity of the joint
o Wrist pain that occurs at night or while rest­ing
o Wrist pain that per­sists beyond a few days
o Inabil­ity to straighten or flex the joint
o Swelling or sig­nif­i­cant bruis­ing around the joint or fore­arm
o Signs of an infec­tion, includ­ing fever, red­ness, warmth
o Any other unusual symptoms

What are the best treat­ments for wrist pain?
The treat­ment of wrist pain depends entirely on the cause of the prob­lem. There­fore, it is of utmost impor­tance that you under­stand the cause of your symp­toms before embark­ing on a treat­ment pro­gram. If you are unsure of your diag­no­sis, or the sever­ity of your con­di­tion, you should seek med­ical advice before begin­ning any treatment.

Not all treat­ments listed here are appro­pri­ate for every con­di­tion, but may be help­ful in your situation.

* Rest & Activ­ity Mod­i­fi­ca­tion: The first treat­ment for many com­mon con­di­tions that cause wrist pain is to rest the joint, and allow the acute inflam­ma­tion to sub­side. It is impor­tant, how­ever, to use cau­tion when rest­ing the joint, because pro­longed immo­bi­liza­tion can cause a stiff joint. Adjust­ing your activ­i­ties so as not to irri­tate the joint can help pre­vent wors­en­ing of wrist pain.

* Ice and Heat Appli­ca­tion: Ice packs and heat pads are among the most com­monly used treat­ments for wrist pain. So which one is the right one to use, ice or heat? And how long should the ice or heat treat­ments last? Read on for more infor­ma­tion about ice and heat treatment.

* Wrist Sup­port: Sup­port braces can help patients who have either had a recent wrist sprain injury or those who tend to injure their wrists eas­ily. These braces act as a gen­tle sup­port to wrist move­ments. They will not pre­vent severe injuries, but may help you per­form sim­ple activ­i­ties while reha­bil­i­tat­ing from a wrist sprain.

* Anti-Inflammatory Med­ica­tion: Non­s­teroidal anti-inflammatory pain med­ica­tions, com­monly referred to as NSAIDs, are some of the most com­monly pre­scribed med­ica­tions, espe­cially for patients with wrist pain caused by prob­lems such as arthri­tis and tendonitis.

* Cor­ti­sone injec­tions: Cor­ti­sone is a pow­er­ful med­ica­tion that treats inflam­ma­tion, and inflam­ma­tion is a com­mon prob­lem in patients with wrist pain. Dis­cuss with your doc­tor the pos­si­ble ben­e­fits of a cor­ti­sone injec­tion for your wrist pain condition.

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Back Pain during Pregnancy

August 17th, 2009

bpp2976Back pain or dis­com­fort is com­mon dur­ing preg­nancy and should be expected to some degree by most women. Back pain may be expe­ri­enced dur­ing any point of your preg­nancy; how­ever, it most com­monly occurs later in the preg­nancy as the weight of the baby increases. Back pain can dis­rupt your daily rou­tine or inter­fere with a good night of sleep. The good news is there are steps you can take to man­age the back pain that you expe­ri­ence.
How com­mon is back pain dur­ing pregnancy?

You are not alone if you are expe­ri­enc­ing back pain dur­ing your preg­nancy. The preva­lence varies with reports, show­ing between 50 to 70 per­cent of all preg­nant women hav­ing back pain.
What causes back pain dur­ing pregnancy?

Back pain dur­ing preg­nancy is related to a num­ber of fac­tors. Some women begin to expe­ri­ence lower back pain with the onset of preg­nancy. Women who are most at risk for back pain are those who are over­weight or had back pain prior to preg­nancy. Here is a list of poten­tial causes of back pain or dis­com­fort dur­ing pregnancy:

* Increase of hor­mones – hor­mones released dur­ing preg­nancy allow lig­a­ments in the pelvic area to soften and the joints to become looser in prepa­ra­tion for the birthing process of your baby; this shift in joints and loos­en­ing of lig­a­ments may affect the sup­port your back nor­mally expe­ri­ences
* Cen­ter of grav­ity – your cen­ter of grav­ity will grad­u­ally move for­ward as your uterus and baby grow, which causes your pos­ture to change
* Addi­tional weight – your devel­op­ing preg­nancy and baby cre­ate addi­tional weight that your back must sup­port
* Pos­ture or posi­tion – poor pos­ture, exces­sive stand­ing, and bend­ing over can trig­ger or esca­late the pain you expe­ri­ence in your back
* Stress – stress usu­ally finds the weak spot in the body, and because of the changes in your pelvic area, you may expe­ri­ence an increase in back pain dur­ing stress­ful peri­ods of your pregnancy

How can you pre­vent or min­i­mize back pain dur­ing pregnancy?

Back pain may not be pre­vented com­pletely, but there are things that you can do to reduce the sever­ity or fre­quency. Here are a few steps you can take to help reduce the back pain you are experiencing:

* Use exer­cises approved by your health care provider that sup­port and help strengthen the back and abdomen

* Squat to pick up some­thing ver­sus bend­ing over
* Avoid high heels and other shoes that do not pro­vide ade­quate sup­port
* Avoid sleep­ing on your back
* Wear a sup­port belt under your lower abdomen
* Make sure your back is aligned using a chi­ro­prac­tor
* Get plenty of rest. Ele­vat­ing your feet is also good for your back

How can you treat back pain dur­ing pregnancy?

There are a num­ber of things you can do to treat back pain dur­ing preg­nancy. Some of the steps you take to avoid back pain may also be used to treat cur­rent back pain. Here are some other com­mon interventions:

* Ice or heat
* Braces or sup­port devices
* Sleep on your left side and use a sup­port pil­low under your knees
* Med­ica­tions used to treat inflam­ma­tion
* Use a licensed health care pro­fes­sional such as a chi­ro­prac­tor or mas­sage therapist

When to con­tact your health care provider?

Expe­ri­enc­ing back pain itself is usu­ally not a rea­son to con­tact your health care provider, but there are sit­u­a­tions where con­tact­ing your provider is nec­es­sary. You want to con­tact your health care provider if you are expe­ri­enc­ing any of the following:

* Severe back pain
* Increas­ingly severe or abrupt-onset of back pain
* Rhyth­mic cramp­ing pains; this could be a sign of preterm labor

Severe back pain may be related to pregnancy-associated osteo­poro­sis, ver­te­bral pregnancy-back-pain-suffererosteoarthri­tis, or sep­tic arthri­tis. These are not com­mon, but it is some­thing your health care provider will exam­ine if you are expe­ri­enc­ing severe back pain.
Your Next Steps:

* Begin an approved exer­cise pro­gram to sup­port your back and abdomen
* Set aside a cou­ple of times a day where you can take a nap or get off your feet
* Find a Chi­ro­prac­tor in your area
* Pur­chase a sup­port belt
* Pur­chase a sleep aid pillow

Com­piled using infor­ma­tion from the fol­low­ing sources:

Dan­forth Obstet­rics and Gyne­col­ogy Ninth Ed. Scott, James. Gibbs, et al, Ch. 1

Williams’s Obstet­rics Twenty-Second Ed. Cun­ning­ham, F. Gary, et al, Ch. 8

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Posted in Back, Abdomen & Waist Pain Topics

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Understanding STRESS

August 10th, 2009

Mod­ern life is full of has­sles, dead­lines, frus­tra­tions, and demands. For many peo­ple, stress is so com­mon­place that it has become a way of life. Stress isn’t always bad. In small doses, it can help you per­form under pres­sure and moti­vate you to do your best. But when you’re con­stantly run­ning in emer­gency mode, your mind and body pay the price.

If you fre­quently find your­self feel­ing fraz­zled and over­whelmed, it’s time to take action to bring your ner­vous sys­tem back into bal­ance. You can pro­tect your­self by learn­ing how to rec­og­nize the signs and symp­toms of stress and tak­ing steps to reduce its harm­ful effects.

Stress is a nor­mal phys­i­cal response to events that make you feel threat­ened or upset your bal­ance in some way. When you sense dan­ger – whether it’s real or imag­ined – the body’s defenses kick into high gear in a rapid, auto­matic process known as the “fight-or-flight” reac­tion, or the stress response.

The stress response is the body’s way of pro­tect­ing you. When work­ing prop­erly, it helps you stay focused, ener­getic, and alert. In emer­gency sit­u­a­tions, stress can save your life – giv­ing you extra strength to defend your­self, for exam­ple, or spurring you to slam on the brakes to avoid an accident.

The stress response also helps you rise to meet chal­lenges. Stress is what keeps you on your toes dur­ing a pre­sen­ta­tion at work, sharp­ens your con­cen­tra­tion when you’re attempt­ing the game-winning free throw, or dri­ves you to study for an exam when you’d rather be watch­ing TV.

But beyond a cer­tain point, stress stops being help­ful and starts caus­ing major dam­age to your health, your mood, your pro­duc­tiv­ity, your rela­tion­ships, and your qual­ity of life.

The Body’s Stress Response

When you per­ceive a threat, your ner­vous sys­tem responds by releas­ing a flood of stress hor­mones, includ­ing adren­a­line and cor­ti­sol. These hor­mones rouse the body for emer­gency action.

Your heart pounds faster, mus­cles tighten, blood pres­sure rises, breath quick­ens, and your senses become sharper. These phys­i­cal changes increase your strength and sta­mina, speed your reac­tion time, and enhance your focus – prepar­ing you to either fight or flee from the dan­ger at hand.

Effects of chronic stress

The body doesn’t dis­tin­guish between phys­i­cal and psy­cho­log­i­cal threats. When you’re stressed over a busy sched­ule, an argu­ment with a friend, a traf­fic jam, or a moun­tain of bills, your body reacts just as strongly as if you were fac­ing a life-or-death sit­u­a­tion. If you have a lot of respon­si­bil­i­ties and wor­ries, your emer­gency stress response may be “on” most of the time. The more your body’s stress sys­tem is acti­vated, the eas­ier it is to trip and the harder it is to shut off.

Long-term expo­sure to stress can lead to seri­ous health prob­lems. Chronic stress dis­rupts nearly every sys­tem in your body. It can raise blood pres­sure, sup­press the immune sys­tem, increase the risk of heart attack and stroke, con­tribute to infer­til­ity, and speed up the aging process. Long-term stress can even rewire the brain, leav­ing you more vul­ner­a­ble to anx­i­ety and depression.

Many health prob­lems are caused or exac­er­bated by stress, including:

* Pain of any kind
* Heart dis­ease
* Diges­tive prob­lems
* Sleep prob­lems
* Depres­sion
* Obe­sity
* Autoim­mune dis­eases
* Skin con­di­tions, such as eczema


How much stress is too much?

Because of the wide­spread dam­age stress can cause, it’s impor­tant to know your own limit. But just how much stress is “too much” dif­fers from per­son to per­son. Some peo­ple roll with the punches, while oth­ers crum­ble at the slight­est obsta­cle or frus­tra­tion. Some peo­ple even seem to thrive on the excite­ment and chal­lenge of a high-stress lifestyle.

Your abil­ity to tol­er­ate stress depends on many fac­tors, includ­ing the qual­ity of your rela­tion­ships, your gen­eral out­look on life, your emo­tional intel­li­gence, and genet­ics.
Things that influ­ence your stress tol­er­ance level

* Your sup­port net­work – A strong net­work of sup­port­ive friends and fam­ily mem­bers is an enor­mous buffer against life’s stres­sors. On the flip side, the more lonely and iso­lated you are, the greater your vul­ner­a­bil­ity to stress.
* Your sense of con­trol – If you have con­fi­dence in your­self and your abil­ity to influ­ence events and per­se­vere through chal­lenges, it’s eas­ier to take stress in stride. Peo­ple who are vul­ner­a­ble to stress tend to feel like things are out of their con­trol.
* Your atti­tude and out­look – Stress-hardy peo­ple have an opti­mistic atti­tude. They tend to embrace chal­lenges, have a strong sense of humor, accept that change is a part of life, and believe in a higher power or pur­pose.
* Your abil­ity to deal with your emo­tions. You’re extremely vul­ner­a­ble to stress if you don’t know how to calm and soothe your­self when you’re feel­ing sad, angry, or afraid. The abil­ity to bring your emo­tions into bal­ance helps you bounce back from adver­sity.
* Your knowl­edge and prepa­ra­tion – The more you know about a stress­ful sit­u­a­tion, includ­ing how long it will last and what to expect, the eas­ier it is to cope. For exam­ple, if you go into surgery with a real­is­tic pic­ture of what to expect post-op, a painful recov­ery will be less trau­matic than if you were expect­ing to bounce back immediately.

Causes of stress

The sit­u­a­tions and pres­sures that cause stress are known as stres­sors. We usu­ally think of stres­sors as being neg­a­tive, such as an exhaust­ing work sched­ule or a rocky relationship.

How­ever, any­thing that puts high demands on you or forces you to adjust can be stress­ful. This includes pos­i­tive events such as get­ting mar­ried, buy­ing a house, going to col­lege, or receiv­ing a promotion.

What causes stress depends, at least in part, on your per­cep­tion of it. Some­thing that’s stress­ful to you may not faze some­one else; they may even enjoy it.

For exam­ple, your morn­ing com­mute may make you anx­ious and tense because you worry that traf­fic will make you late. Oth­ers, how­ever, may find the trip relax­ing because they allow more than enough time and enjoy lis­ten­ing to music while they drive.

Top Ten Stress­ful Life Events

1. Spouse’s death
2. Divorce
3. Mar­riage sep­a­ra­tion
4. Jail term
5. Death of a close rel­a­tive
6. Injury or ill­ness
7. Mar­riage
8. Fired from job
9. Mar­riage rec­on­cil­i­a­tion
10. Retirement

Signs and symp­toms of stress overload

It’s impor­tant to learn how to rec­og­nize when your stress lev­els are out of con­trol. The most dan­ger­ous thing about stress is how eas­ily it can creep up on you. You get used to it. It starts to feels famil­iar – even nor­mal. You don’t notice how much it’s affect­ing you, even as it takes a heavy toll.

The signs and symp­toms of stress over­load can be almost any­thing. Stress affects the mind, body, and behav­ior in many ways, and every­one expe­ri­ences stress dif­fer­ently.
How do you respond to stress?

Psy­chol­o­gist Con­nie Lil­las uses a dri­ving anal­ogy to describe the three most com­mon ways peo­ple respond when they’re over­whelmed by stress:

* Foot on the gas – An angry or agi­tated stress response. You’re heated, keyed up, overly emo­tional, and unable to sit still.
* Foot on the brake – A with­drawn or depressed stress response. You shut down, space out, and show very lit­tle energy or emo­tion.
* Foot on both – A tense and frozen stress response. You “freeze” under pres­sure and can’t do any­thing. You look par­a­lyzed, but under the sur­face you’re extremely agitated.

Keep in mind that the signs and symp­toms of stress can also be caused by other psy­cho­log­i­cal and med­ical prob­lems. If you’re expe­ri­enc­ing any of the warn­ing signs of stress, it’s impor­tant to see a doc­tor for a full eval­u­a­tion. Your doc­tor can help you deter­mine whether or not your symp­toms are stress-related.

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Posted in General Topics, Healthy Life, Mental Health

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Back Pain…, Why?

August 4th, 2009

lower back pain

Back pain is a com­mon com­plaint. Four out of five peo­ple in the United States will expe­ri­ence low back pain at least once dur­ing their lives. It’s one of the most com­mon rea­sons peo­ple go to the doc­tor or miss work.

On the bright side, you can pre­vent most back pain. If pre­ven­tion fails, sim­ple home treat­ment and proper body mechan­ics will often heal your back within a few weeks and keep it func­tional for the long haul. Surgery is rarely needed to treat back pain.

Causes

Your back is an intri­cate struc­ture com­posed of bones, mus­cles, lig­a­ments, ten­dons and disks — the cartilage-like pads that act as cush­ions between the seg­ments of your spine. Back pain can arise from prob­lems with any of these com­po­nent parts. In some peo­ple, no spe­cific cause for their back pain can be found.

Strains

Back pain most often occurs from strained mus­cles and lig­a­ments, from improper or heavy lift­ing, or after a sud­den awk­ward move­ment. Some­times a mus­cle spasm can cause back pain.

Struc­tural problems

In some cases, back pain may be caused by struc­tural prob­lems, such as:

* Bulging or rup­tured disks. Disks act as cush­ions between the ver­te­brae in your spine. Some­times, the soft mate­r­ial inside a disk may bulge out of place or rup­ture and press on a nerve. But many peo­ple who have bulging or her­ni­ated disks expe­ri­ence no pain from the condition.

* Sci­at­ica. If a bulging or her­ni­ated disk presses on the main nerve that trav­els down your leg, it can cause sci­at­ica — sharp, shoot­ing pain through the but­tock and back of the leg.

* Arthri­tis. The joints most com­monly affected by osteoarthri­tis are the hips, hands, knees and lower back. In some cases arthri­tis in the spine can lead to a nar­row­ing of the space around the spinal cord, a con­di­tion called spinal stenosis.

* Skele­tal irreg­u­lar­i­ties. Back pain can occur if your spine curves in an abnor­mal way. If the nat­ural curves in your spine become exag­ger­ated, your upper back may look abnor­mally rounded or your lower back may arch exces­sively. Sco­l­io­sis, a con­di­tion in which your spine curves to the side, also may lead to back pain.

* Osteo­poro­sis. Com­pres­sion frac­tures of your spine’s ver­te­brae can occur if your bones become porous and brittle.

Rare but seri­ous conditions

In rare cases, back pain may be related to:

* Cauda equina syn­drome. This is a seri­ous neu­ro­log­i­cal prob­lem affect­ing a bun­dle of nerve roots that serve your lower back and legs. It can cause weak­ness in the legs, numb­ness in the “sad­dle” or groin area, and loss of bowel or blad­der control.

* Can­cer in the spine. A tumor on the spine can press on a nerve, caus­ing back pain.

* Infec­tion of the spine. If a fever and a ten­der, warm area accom­pany back pain, the cause could be an infection.

Fac­tors that increase your risk of devel­op­ing low back pain include:

* Smoking

* Obesity

* Older age

* Female gender

* Phys­i­cally stren­u­ous work

* Seden­tary work

* Stress­ful job

* Anxiety

* Depression

Most back pain grad­u­ally improves with home treat­ment and self-care. Although the pain may take sev­eral weeks to dis­ap­pear com­pletely, you should notice some improve­ment within the first 72 hours of self-care. If not, see your doctor.

In rare cases, back pain can sig­nal a seri­ous med­ical prob­lem. See a doc­tor imme­di­ately if your back pain:

* Is con­stant or intense, espe­cially at night or when you lie down

* Spreads down one or both legs, espe­cially if the pain extends below the knee

* Causes weak­ness, numb­ness or tin­gling in one or both legs

* Causes new bowel or blad­der problems

* Is asso­ci­ated with pain or pul­sa­tion (throb­bing) in the abdomen, or fever

* Fol­lows a fall, blow to your back or other injury

* Is accom­pa­nied by unex­plained weight loss

Also, see your doc­tor if you start hav­ing back pain for the first time after age 50, or if you have a his­tory of can­cer, osteo­poro­sis, steroid use, or drug or alco­hol abuse.

Diag­nos­tic tests aren’t usu­ally nec­es­sary to con­firm the cause of your back pain. How­ever, if you do see your doc­tor for back pain, he or she will exam­ine your back and assess your abil­ity to sit, stand, walk and lift your legs. He or she may also test your reflexes with a rub­ber reflex ham­mer. These assess­ments help deter­mine where the pain comes from, how much you can move before pain forces you to stop and whether you have mus­cle spasms. They will also help rule out more seri­ous causes of back pain.

If there is rea­son to sus­pect that you have a tumor, frac­ture, infec­tion or other spe­cific con­di­tion that may be caus­ing your back pain, your doc­tor may order one or more tests:

* X-ray. These images show the align­ment of your bones and whether you have arthri­tis or bro­ken bones. X-ray images won’t directly show prob­lems with your spinal cord, mus­cles, nerves or disks.

* Mag­netic res­o­nance imag­ing (MRI) or com­put­er­ized tomog­ra­phy (CT) scans. These scans can gen­er­ate images that may reveal her­ni­ated disks or prob­lems with bones, mus­cles, tis­sue, ten­dons, nerves, lig­a­ments and blood vessels.

* Bone scan. In rare cases, your doc­tor may use a bone scan to look for bone tumors or com­pres­sion frac­tures caused by osteo­poro­sis. In this pro­ce­dure, you’ll receive an injec­tion of a small amount of a radioac­tive sub­stance (tracer) into one of your veins. The sub­stance col­lects in your bones and allows your doc­tor to detect bone prob­lems using a spe­cial camera.

* Nerve stud­ies (elec­tromyo­g­ra­phy, or EMG). This test mea­sures the elec­tri­cal impulses pro­duced by the nerves and the responses of your mus­cles. Stud­ies of your nerve-conduction path­ways can con­firm nerve com­pres­sion caused by her­ni­ated disks or nar­row­ing of your spinal canal (spinal stenosis).

Most back pain gets bet­ter with a few weeks of home treat­ment and care­ful atten­tion. A reg­u­lar sched­ule of over-the-counter pain reliev­ers may be all that you need to improve your pain. A short period of bed rest is okay, but more than a cou­ple of days actu­ally does more harm than good. If home treat­ments aren’t work­ing, your doc­tor may sug­gest stronger med­ica­tions or other therapy.

Med­ica­tions

Your doc­tor may pre­scribe non­s­teroidal anti-inflammatory drugs or in some cases, a mus­cle relax­ant, to relieve mild to mod­er­ate back pain that doesn’t get bet­ter with over-the-counter pain reliev­ers. Nar­cotics, such as codeine or hydrocodone, may be used for a short period of time with close super­vi­sion by your doctor.

Low doses of cer­tain types of anti­de­pres­sants — par­tic­u­larly tri­cyclic anti­de­pres­sants, such as amitripty­line — have been shown to relieve chronic back pain, inde­pen­dent of their effect on depression.

Phys­i­cal ther­apy and exercise

A phys­i­cal ther­a­pist can apply a vari­ety of treat­ments, such as heat, ice, ultra­sound, elec­tri­cal stim­u­la­tion and muscle-release tech­niques, to your back mus­cles and soft tis­sues to reduce pain. As pain improves, the ther­a­pist can teach you spe­cific exer­cises to increase your flex­i­bil­ity, strengthen your back and abdom­i­nal mus­cles, and improve your pos­ture. Reg­u­lar use of these tech­niques will help pre­vent pain from com­ing back.

Injec­tions

If other mea­sures don’t relieve your pain and if your pain radi­ates down your leg, your doc­tor may inject cor­ti­sone — an anti-inflammatory med­ica­tion — into the space around your spinal cord (epidural space). A cor­ti­sone injec­tion helps decrease inflam­ma­tion around the nerve roots, but the pain relief usu­ally lasts less than six weeks.

In some cases, your doc­tor may inject numb­ing med­ica­tion into or near the struc­tures believed to be caus­ing your back pain. Early stud­ies indi­cate that bot­u­lism toxin (Botox) also may help relieve back pain, per­haps by par­a­lyz­ing strained mus­cles in spasm. Botox injec­tions typ­i­cally wear off within three to four months.

Surgery

Few peo­ple ever need surgery for back pain. There are no effec­tive sur­gi­cal tech­niques for mus­cle– and soft-tissue-related back pain. Surgery is usu­ally reserved for pain caused by a her­ni­ated disk. If you have unre­lent­ing pain or pro­gres­sive mus­cle weak­ness caused by nerve com­pres­sion, you may ben­e­fit from surgery. Types of back surgery include:

* Fusion. This surgery involves join­ing two ver­te­brae to elim­i­nate painful move­ment. A bone graft is inserted between the two ver­te­brae, which may then be splinted together with metal plates, screws or cages. A draw­back to the pro­ce­dure is that it increases the chances of arthri­tis devel­op­ing in adjoin­ing vertebrae.

* Disk replace­ment. An alter­na­tive to fusion, this surgery inserts an arti­fi­cial disk as a replace­ment cush­ion between two vertebrae.

* Par­tial removal of disk. If disk mate­r­ial is press­ing or squeez­ing a nerve, your doc­tor may be able to remove just the por­tion of the disk that’s caus­ing the problem.

* Par­tial removal of a ver­te­bra. If your spine has devel­oped bony growths that are pinch­ing your spinal cord or nerves, sur­geons can remove a small sec­tion of the offend­ing ver­te­bra, to open up the passage.

You may be able to avoid back pain by improv­ing your phys­i­cal con­di­tion and learn­ing and prac­tic­ing proper body mechanics.

To keep your back healthy and strong:

* Exer­cise. Reg­u­lar low-impact aer­o­bic activ­i­ties — those that don’t strain or jolt your back — can increase strength and endurance in your back and allow your mus­cles to func­tion bet­ter. Walk­ing and swim­ming are good choices. Talk with your doc­tor about which activ­i­ties are best for you.

* Build mus­cle strength and flex­i­bil­ity. Abdom­i­nal and back mus­cle exer­cises (core-strengthening exer­cises) help con­di­tion these mus­cles so that they work together like a nat­ural corset for your back. Flex­i­bil­ity in your hips and upper legs aligns your pelvic bones to improve how your back feels.

* Quit smok­ing. Smok­ers have dimin­ished oxy­gen lev­els in their spinal tis­sues, which can hin­der the heal­ing process.

* Main­tain a healthy weight. Being over­weight puts strain on your back mus­cles. If you’re over­weight, trim­ming down can pre­vent back pain.

Use proper body mechanics:

* Stand smart. Main­tain a neu­tral pelvic posi­tion. If you must stand for long peri­ods of time, alter­nate plac­ing your feet on a low foot­stool to take some of the load off your lower back.

* Sit smart. Choose a seat with good lower back sup­port, arm rests and a swivel base. Con­sider plac­ing a pil­low or rolled towel in the small of your back to main­tain its nor­mal curve. Keep your knees and hips level.

* Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lift­ing and twist­ing simul­ta­ne­ously. Find a lift­ing part­ner if the object is heavy or awkward.

Many peo­ple choose hands-on ther­a­pies to ease their back pain:

* Chi­ro­prac­tic care. Back pain is one of the most com­mon rea­sons that peo­ple see a chi­ro­prac­tor. If you’re con­sid­er­ing chi­ro­prac­tic care, talk to your doc­tor about the most appro­pri­ate spe­cial­ist for your type of prob­lem. In addi­tion to chi­ro­prac­tors, many osteo­pathic doc­tors and some phys­i­cal ther­a­pists have train­ing in spinal manipulation.

* Acupunc­ture. Some peo­ple with low back pain report that acupunc­ture helps relieve their symp­toms. The National Insti­tutes of Health has found that acupunc­ture can be an effec­tive treat­ment for some types of chronic pain. In acupunc­ture, the prac­ti­tioner inserts ster­il­ized stain­less steel nee­dles into the skin at spe­cific points on the body.

* Mas­sage. If your back pain is caused by tense or over­worked mus­cles, mas­sage ther­apy may help loosen knot­ted mus­cles and pro­mote relaxation.

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Posted in Back, Abdomen & Waist Pain Topics

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