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Respiratory Tract Infections; Causes, Symptoms, Treatment

Respiratory tract infections (RTI) are illnesses caused by an acute infection which involves the upper respiratory tract including the nose, sinuses, pharynx or larynx. This commonly includes nasal obstruction, sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold.[3]Most infections are viral in nature and in other instances the cause is bacterial.[rx] Upper respiratory tract infections can also be fungal or helminth in origin, but these are far less common.[rx]

Upper respiratory tract infection (URTI) or the common cold is a symptom complex usually caused by several families of the virus; these are the rhinovirus, coronavirus, parainfluenza, respiratory syncytial virus (RSV), adenovirus, human metapneumovirus, and influenza. Occasionally the enterovirus is implicated in summer. Recently, the newly discovered bocavirus (related to the parvovirus) has also been linked to URTI. The term “URTI” is probably a misnomer as it incorrectly implies an absence of lower respiratory tract symptoms. URTI occurs commonly in both children and adults and is a major cause of mild morbidity. URTIs have a high cost to society, being responsible for missed work and unnecessary medical care. Occasionally they have serious sequelae. Often regarded as trivial, URTIs do not receive serious attention in medical school curricula.

Types of RTIs

  • Upper respiratory tract infections: Symptoms occur mainly in the nose and throat. Viral upper respiratory tract infections may occur at any age and include the common cold and influenza.

  • Lower respiratory tract infections: Symptoms occur in the windpipe, airways, and lungs. Viral lower respiratory tract infections are more common among children and include croup, bronchiolitis, and pneumonia.

There are several different types. They’re usually grouped into upper and lower RTIs.

Upper RTIs (sinuses and throat) Lower RTIs (airways and lungs)
Common cold Bronchitis
Sinusitis (sinus infection) Bronchiolitis
Tonsillitis Chest infection
Laryngitis Pneumonia (lung infection)
  • A URI may be classified by the area inflamed. Rhinitis affects the nasal mucosa, while rhinosinusitis or sinusitis affects the nose and paranasal sinuses, including frontal, ethmoid, maxillary, and sphenoid sinuses.
  • Nasopharyngitis (rhinopharyngitis or the common cold) affects the nares, pharynx, hypopharynx, uvula, and tonsils generally.
  • Without involving the nose, pharyngitis inflames the pharynx, hypopharynx, uvula, and tonsils. Similarly, epiglottitis (supraglottitis) inflames the superior portion of the larynx and supraglottic area; laryngitis is in the larynx; laryngotracheitis is in the larynx, trachea, and subglottic area; and tracheitis is in the trachea and subglottic area.

Causes of Respiratory Tract Infection

  • Acute pharyngitis
  • Acute ear infection
  • Common cold
  • Bronchitis
  • Pneumonia
  • Bronchiolitis

Flu can be an upper or lower RTI

  • Common cold
  • Sinusitis – Inflammation of the sinuses
  • Epiglottitis – Inflammation of the epiglottis, the upper part of the trachea that helps protect the airways from foreign particles – Swelling here is dangerous because it can block air flow
  • Laryngitis – Inflammation of the larynx (voice box)
  • Bronchitis – Inflammation of the bronchial tubes

Causes and Risk Factors

Lower Respiratory Tract Infections in Children and Important Etiologic Agents

Syndrome Etiologic agents
  • Bronchiolitis
RSV, hMPV, PIV, adenovirus, coronaviruses, influenza viruses, Chlamydophila pneumoniae, Mycoplasma pneumoniae, rhinovirus, bocavirus,
  • Exacerbations of Wheezing/Asthma
RSV, hMPV, rhinovirus, adenovirus, PIV, coronaviruses, influenza viruses, Chlamydophila pneumoniae, Mycoplasma pneumoniae, bocavirus
Croup PIV, Influenza, adenovirus,
  • Pneumonia
Influenza, Streptococcus pneumoniae, Mycoplasma pneumoniae, PIV, adenovirus, RSV,hMPV, Streptococcus pyogenes, Staphylococcus aureus
  • Pneumonitis in Transplant Recipients
RSV, PIV, influenza, hMPV, adenovirus, rhinovirus

NOTE. Pathogens in bold are thought to be the most common etiologies. hMPV, human metapneumovirus; PIV, parainfluenza virus 1, 2, 3; RSV, respiratory syncytial virus.

URIs can be caused by both viruses and bacteria. There are several sub-types within each of these categories. For viruses, these include:

  • Rhinovirus
  • Adenovirus
  • Coxsackie virus
  • Parainfluenza virus
  • Respiratory syncytial virus
  • Hyman metapneumovirus

For bacteria, these include

  • Group A beta-hemolytic streptococci (GABHS)
  • Corynebacterium diphtheriae (diphtheria)
  • Neisseria gonorrhoeae (gonorrhea)
  • Chlamydia pneumoniae (chlamydia)
  • Group C beta-hemolytic streptococci

Other Causes

Typical Bacterial Infections

  • Haemophilus influenzae
  • Staphylococcus aureus
  • Klebsiella pneumonia

Atypical Bacterial Infections

  • Legionella pneumophila
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Chlamydia psittaci

Parasitic infections

  • Respiratory cryptosporidiosis

Viral infections

  • Adenovirus
  • Influenza A virus
  • Influenza B virus
  • Human parainfluenza viruses
  • Human respiratory syncytial virus
  • SARS coronavirus
  • Middle East respiratory syndrome coronavirus
  • Aspiration pneumonia

Several actions, events or conditions can increase the risk of a URI, including

  • When someone sick sneezes or coughs without covering their nose and mouth. This causes droplets containing viruses to be sprayed into the air.
  • Closed areas or crowded conditions, such as hospitals, institutions, schools and daycare centers.
  • When you touch your nose or your eyes—infection occurs when secretion touches the nose or eyes.
  • During fall and winter (September to March) while people are more likely to be inside.
  • When humidity is low—indoor heating promotes the survival of many viruses that lead to URIs.
  • If you have a weakened immune system.
  • Chronic respiratory disease
  • Chronic renal disease
  • Chronic liver disease
  • Diabetes
  • Serious central nervous system diseases (cerebral vascular accident, transient ischaemic attack, Parkinson’s disease, dementia, and multiple sclerosis)
  • Rheumatoid arthritis
  • Cancer
  • Osteoporosis

Increased age (>60 years), especially in the presence of:

  • use of benzodiazepines or antidepressants
  • heart failure
  • male sex

Risk factors for poor prognosis

Diabetes, especially in the presence of

  • Exacerbation of COPD
  • Antibiotics within the previous month
  • Pneumonia
  • Heart failure
  • Hospitalisation
  • Current use of glucocorticoids or diabetic medication

Age >80 years, and

  • Diabetes (especially insulin dependent diabetes)
  • Exacerbation of COPD,
  • ≥2 courses oral steroids in previous year
  • Recent antibiotic use
  • Housebound (Socioeconomic factors had little additive influence on outcomes)
  • Smoking
  • Male sex
  • Aged 21–40 years

Modified CRB-65 score

1 point for each of the following

  • Age >65 years
  • Presence of new onset pneumonia-associated mental confusion
  • Hypotension with systolic blood pressure <90 mmHg
  • Respiratory rate >30/minute

Symptoms

Symptoms of a URI may include

  • Runny nose, nasal congestion, sneezing, cough and sputum production (these are considered the most common symptoms)
  • Fever
  • Fatigue
  • A headache
  • Pain during swallowing
  • Wheezing
  • congestion, either in the nasal sinuses or lungs
  • a runny nose
  • a cough
  • a sore throat
  • body aches
  • fatigue
  • a fever over 103˚ F (39˚ C) and chills
  • difficulty breathing
  • dizziness
  • loss of consciousness

Acute upper respiratory tract infections include rhinitis, pharyngitis, tonsillitis, and laryngitis. Symptoms of URTIs commonly include

  • Cough
  • Sore throat
  • Runny nose
  • Nasal congestion
  • Headache
  • Low-grade fever
  • Facial pressure
  • Sneezing
  • Malaise
  • Myalgias

The onset of symptoms usually begins one to three days after exposure and lasts 7–10 days, and can persist up to 3 weeks.

Diagnosis 

If your child has a complicated respiratory infection, the doctor may perform one or more of these tests:

  • Blood tests. These tests are performed to see if bacteria are in the blood.
  • Imaging tests. A chest X-ray or computed tomography (CT) scan may be performed to check for infections in the chest, lungs, orbits or sinuses.
  • Throat or nasal swab. This test takes a sample of cells and mucus from the nose, throat or tonsils to find the cause of the infection.

Differential Diagnosis

  • Common Cold
  • Allergic rhinitis
  • Sinusitis
  • Tracheobronchitis
  • Pneumonia
  • Atypical Pneumonia
  • Pertussis
  • Epiglottitis
  • Streptococcal Pharyngitis/Tonsillitis
  • Infectious Mononucleosis

Treatment

In most cases, people with URIs know what they have and are visiting the doctor to find symptom relief. Most diagnoses can be made using medical history and a physical exam. If needed, tests like throat swabs, X-rays or CT scans might be used for a diagnosis.

URI treatments include:

  • Cough suppressants
  • Expectorants
  • Vitamin C or zinc
  • Nasal decongestants
  • Steam inhalation and gargling with salt water
  • Analgesics like acetaminophen and NSAIDs can help with fever, aches and pains
  • Treatment of the symptoms of upper respiratory infection is usually continued until the infection has resolved.

The 2008 National Institute for Clinical Excellence (NICE) guidelines recommend no antibiotics or delayed antibiotics for most patients with RTI .

NICE guidance on antibiotic prescribing for self-limiting respiratory tract infections in primary care

Prescribe antibiotics for immediate use and/or arrange further appropriate investigation and management for the following patients:

  • Those who are systemically very unwell
  • Those with symptoms and signs suggesting serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications)
  • Those at high risk of serious complications because of pre-existing comorbidity (including patients with heart, lung, renal, liver, or neuromuscular disease, immunosuppression, or cystic fibrosis, and young children who were born prematurely)
Those who are
  • >65 years with acute cough and two or more of the following criteria, or
  • >80 years with one or more of the following criteria
    • Admission to hospital in previous year
    • Diabetes (type 1 or type 2)
    • History of congestive heart failure
    • Current use of glucocorticoids

Consider prescribing antibiotics for immediate use in the following situations

  • Bilateral acute otitis media in children under 2 years
  • Acute otitis media in children with otorrhoea
  • Acute sore throat or acute tonsillitis when ≥3 Centor criteria are present
  • For all others adults and children (over 3 months) with acute otitis media, acute sore throat (or tonsillitis), common cold, acute rhinosinusitis, acute cough, or acute bronchitis, a non-prescribing or delayed-prescribing approach should be adopted.
  • Explore the patient’s concerns and expectations, and consider these when discussing management options.
  • Advise on the usual course of the illness and the average total illness duration.
  • Advise patients how to manage symptoms, including fever.
  • Provide advice and when to re-consult and /or use a delayed prescription.

Treatment

Amoxicillin 500 mg (children: 15mg/kg; maximum 500mg) orally every 8 hours for 5 days

or

doxycycline 100 mg (children >8 years: 2mg/kg; maximum 100 mg) orally every 12 hours for 5 days (contraindicated during pregnancy)

or

sulfamethoxazole 800mg + trimethoprim 160mg (children: 20mg/kg + 4mg/kg; maximum 800mg + 160 mg) orally every 12 hours for 5 days.

Cefalosporins and fluoroquinolones are not recommended for bronchitis.

Acute exacerbations of chronic bronchitis

Acute exacerbations of chronic bronchitis are often due to viral infection and do not require treatment with antimicrobials. Antimicrobial treatment should, however, be considered in patients with increasing cough, dyspnoea and increased production and purulence of sputum. The most common causative organisms are H. influenzae, Moraxella catarrhalis and S. pneumoniae.

Doses refer to adults, as this condition is rarely found in children.

Amoxicillin 500 mg orally every 8 hours for 5 days

or

amoxicillin 500mg + clavulanic acid orally every 8 hours for 5 days

or

sulfamethoxazole 800mg + trimethoprim 160 mg orally every 12 – 24 hours for 5 days.

Chronic purulent bronchial infection and chronic airway disease are predominantly diseases of adults. Chronic suppurative lung disease in children (e.g. bronchiectasis) may occasionally require treatment with amoxicillin (30mg/kg (maximum 1g) orally every 8 hours for 5 days) or chloramphenicol (25mg/kg (maximum 1g) i.v. or i.m. every 6 hours for 5 days). Cystic fibrosis infections require specialist clinical management and laboratory services.

  • Acetaminophen –  Read all cold medicine package labels. Do not take more than one drug that contains acetaminophen. Taking too much acetaminophen can damage your liver. Acetaminophen doses should not exceed 4 grams per day. Individuals with liver damage or liver problems should not exceed 2 grams of acetaminophen per day.
  • Antibiotics – are sometimes used to treat upper respiratory infections if a bacterial infection is suspected or diagnosed. These conditions may include strep throat, bacterial sinusitis, or epiglottitis. Antivirals may occasionally be recommended by doctors in patients who are immunocompromised (poor immune system). The treating doctor can determine which antibiotic would be the best option for a particular infection.
  • Nonsteroidal anti-inflammatory drugs  – such as ibuprofen (Motrin, Advil) can be used for body aches and fever.
  • Antihistamines –  such as diphenhydramine (Benadryl) are helpful in decreasing nasal secretions and congestions.
  • Nasal ipratropium  – (topical) can be used to diminish nasal secretions.
  • Cough medications – (antitussives) can be used to reduce a cough. Many cough medications are commercially available such as dextromethorphan, guaifenesin (Robitussin), and codeine all have shown benefits in reducing cough in upper respiratory infections.
  • Target likely organisms with first-line drugs – Amoxicillin, Amoxicillin/Clavulanate
  • Use shortest effective course – Should see improvement in 2–3 days. Continue treatment for 7 days after symptoms improve or resolve (usually a 10–14-day course).
  • Honey – can be used in reducing cough.
  • Steroids  – such as dexamethasone  and prednisone orally  are sometimes used to reduce inflammation of the airway passage and decrease swelling and congestion.
  • Decongestants – such as pseudoephedrine oral, phenylephrine  can be used to reduce nasal congestion (generally not recommended in children less than 2 years of age and not recommended for individuals with high blood pressure).
  • Oxymetazoline –  nasal solution is a decongestant, but should only be used for short-term.
  • Combination medications containing many of these components are also widely available over the counter.

To ease the discomfort from specific cold and flu symptoms, consider using the following types of OTC medicines

  • To reduce fever and pain — analgesics- Acetaminophen is generally preferred. Ibuprofen or naproxen is also commonly used. Aspirin should be avoided due to its risk of developing Reye’s syndrome. (Reye’s syndrome is a condition that affects all body organs and is most harmful to the brain and liver.)
  • To dry out the nose — antihistamines –  Try an antihistamine, such as diphenhydramine. Because these products can make you sleepy, avoid driving and other complex tasks while taking these medicines. Loratadine available is a non-drowsy alternative, but may not be as effective as other antihistamines for reducing cold and flu symptoms.
  • To relieve a stuffy, clogged nose — decongestants  – Try an oral decongestant, such as pseudoephedrine. However, insomnia, nervousness, and irritability can occur when taking these drugs. Those who are pregnant or have uncontrolled high blood pressure should avoid pseudoephedrine products. Often decongestants are combined with other drugs (especially antihistamines) in OTC medicines. A “-D” at the end of a medicine’s name means it includes an oral decongestant.
  • To relieve a runny nose or sinus pressure — nasal steroids- Medications like fluticasone available without a prescription) or mometasone; prescription needed) can relieve symptoms. These medicines are also used for seasonal allergies. These are not the same as  or other OTC nasal preparations. Antihistamines will also help.
  • To make blowing your nose easier or loosening cough/mucus production — expectorants: Try guaifenesin . These products help thin the thick, discolored drainage coming out of the nose and mouth.
  • To reduce coughing — antitussives –  Dextromethorphan can help suppress cough.
  • To relieve a sore throat – Try throat lozenges or gargle with warm salt water a few times a day. Analgesics are also helpful.
  • Oral zinc supplementation – has been used in recent years to shorten the duration and reduce the severity of symptoms of upper respiratory infection and common cold. This therapy has been studied in children with upper respiratory infection and the results are mixed. The FDA has not approved the use of oral zinc to treat the common cold or upper respiratory infections. There are reports of nausea and unpleasant taste caused by oral zinc.
  • Topical nasal zinc products  – has been also used to attenuate the symptoms of upper respiratory infection. Some studies suggest loss of the sense of smell associated with the use of this over the counter product.
  • The use of oral vitamin C – is thought to shorten the duration of upper respiratory infection symptoms, but research data are inconclusive regarding the benefits of vitamin C.

Complications of a Respiratory Infection may include

  • Empyema – Empyema is a collection of pus beside the lungs, caused by a bacterial infection that can lead to life-threatening problems such as sepsis (bacteria in the blood) and shock. Symptoms include fever, cough, shortness of breath and chest pain.
  • Lung abscess – A lung abscess is a pus-filled cavity in the lung surrounded by inflamed tissue. It is usually caused by a severe infection such as pneumonia or tuberculosis or from inhaling material into the lungs from the mouth.
  • Potts puffy tumor – This is an uncommon complication of sinusitis (a type of upper respiratory tract infection that causes inflammation of the sinus cavities in the skull). It is an abscess of the forehead area with frontal swelling. Potts puffy tumor is usually seen in late childhood or adolescence. Symptoms include red, tender swelling in the mid-forehead, headache and fever.
  • Orbital cellulitis – Orbital cellulitis is another possible complication of sinusitis. This is an infection of the tissue within the eye socket and around the eye. Symptoms include pain, swelling, red eye, fever, a bulging eye, impaired vision and impaired eye movements.
  • Orbital abscess = Also a further complication of sinusitis causing orbital cellulitis, orbital abscess is a collection of bacteria and pus behind the eye. Symptoms include eye pain, bulging of the eye, redness of the eye, changes in vision and fever.
  • Mastoiditis – Mastoiditis is a complication of otitis (a type of upper respiratory tract infection that causes inflammation and possible infection of the middle ear). This is a serious bacterial infection that affects the mastoid bone behind the ear. Symptoms may include ear pain, fever, headache, drainage from the infected ear, redness, swelling and tenderness in the affected ear.dentifying patients at risk of poor prognosis for developing pneumonia

Non-antibiotic management of RTIs

  • Beta-2 agonists for acute bronchitis (mainly oral agents): little evidence for routine use in acute bronchitis in primary care, but if there is evidence of airflow obstruction with the symptoms, some adults may derive some symptomatic benefit. Only two included studies were in children, and there was no evidence of benefit.
  • Over-the-counter (OTC) medications for acute cough: review of antitussives, expectorants, mucloytics, antihistamine/decongestant combinations, other drug combinations and antihistamines concluded there was no good evidence for or against the effectiveness of OTC medications in children or adults, but that the few studies were mostly of poor design, with small sample sizes and that interventions and outcomes were so diverse that is was difficult to generalise the findings. In 2008, the Commission on Human Medicines (CHM) advised about the unfavourable risk/benefit ratio of these medicines in children. The Medicines and Healthcare Regulatory Authority (MHRA) subsequently amended the product licence for cough medications for children due to safety concerns. They should not be used by children under 6 years of age, and can only be purchased for children aged 6–12 years in a pharmacy. The MHRA have also recommended that certain combinations should be phased out (the combination of cough suppressant and expectorant).
  • Corticosteroids for sore throats: a systematic review and meta-analysis of eight trials involving 369 children and 374 adults found that despite heterogeneity, corticosteroids significantly reduced sore throat pain in addition to antibiotic therapy mainly in patients with severe or exudative sore throat.
  • Vitamin C for preventing and treating pneumonia: review of five trials carried out in extraordinary conditions suggested there may be a benefit at both preventing and treating pneumonia, but possibly only in those with low plasma vitamin C levels.
  • Vitamin C for preventing and treating the common cold: no benefit in the general population, but six trials which showed some evidence may reduce the risk of catching the common cold by half in individuals undergoing short periods of acute physical or cold stress or both (for example, marathon runners and soldiers training at sub-arctic conditions); poor study designs showed inconsistent results on effect of duration or severity of a cold.
  • Vitamin A for preventing acute LRTIs in children up to 7 years of age: some evidence for benefit if poor nutritional status, but some studies actually found increased chances of infection or worsened symptoms.
  • Echinacea for preventing and treating the common cold: some preparations based on Echinacea purpura might be effective, but no clear evidence of other preparation effectiveness or effectiveness in children.
  • Garlic for the common cold: only one study was eligible for inclusion and showed that people taking garlic every day for 3 months had fewer colds than those taking placebo, but the duration of a cold was similar in both groups; there have been no trials examining whether taking garlic at the time of a cold reduces severity or duration.
  • Chinese medicines for bronchitis, influenza, sore throats, and the common cold: no conclusion due to study design limitations and concerns over lack of safety data.
  • Increased fluids: no evidence for or against, although some evidence from some observational studies that may be harmful.
  • Heated or humidified air for the common cold: in some studies this helped, in others it did not; no studies included children.
  • Humidified air inhalation for treating croup: three small studies in emergency settings in a total of 135 patients with moderate to severe croup showed there did not appear to be any benefit, but there have been no studies in primary care.
  • Non-steroidal anti-inflammatory drugs for the common cold: nine studies with 1064 patients showed improvement in most analgesia-related symptoms, but no clear evidence of improvement in runny noses or cough.
  • Reviews of zinc and the homeopathic remedy, Oscillococcinum, have been withdrawn from the Cochrane database.

Modifying Antibiotic Prescribing

  • Antibiotics are more likely to be prescribed when patients expect them.However, patients frequently consult when antibiotics are not their main expectation, and clinicians are not able to discriminate well between those patients who expect and those who do not expect antibiotics. Perception of patient pressure is a strong independent predictor of antibiotic prescribing., It is a major driver in prescribing antibiotics when faced with normal chest auscultation.
  • Consultations about RTIs are sometimes seen as an opportunity ‘catch-up’ and information-sharing can be inadequate. Sharing information about the likely natural history of RTIs helps set realistic expectations about illness duration, which may reduce expectations (or perceived expectations) for antibiotics and reduce future consulting.
  • RCTs of interventions incorporating shared decision making during consultations, including the use of an interactive booklet in the consultation, demonstrated reductions in antibiotic prescribing without adversely effecting recovery or satisfaction with care.

Delayed Prescriptions

  • A Cochrane review that included nine trials found that delayed prescribing can reduce antibiotic use for acute respiratory infections without harming patients. Delayed prescribing compared to immediate antibiotics was associated with reduced patient satisfaction in three trials, and no difference in two.
  • However, delayed antibiotics may have little advantage over not prescribing them at all where it appears safe to do so. Nevertheless some clinicians find delayed antibiotics are easier to implement than refusing antibiotics altogether, and a time trend analysis of UK data suggested that delayed prescribing was responsible for a 10–15% reduction in antibiotic use by children between 1998 and 2003.

Prevention and Treatment of Seasonal Influenza

Vaccination

  • Systematic reviews of the efficacy (ability of the vaccine to prevent confirmed influenza cases), effectiveness (ability of the vaccine to prevent influenza–like illness) and safety of vaccines are limited by lack of current, well-designed RCTs.
  • A systematic review on the use of influenza vaccination for healthy children found evidence of efficacy in children older than 2 years but little evidence for children under 2, no comparisons of safety, and a marked difference between vaccine efficacy and effectiveness.
  • If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required. A similar review on the use of influenza vaccination for healthy adults found little support for use as a routine public health measure. Even in older people, the effectiveness of influenza vaccination is modest in long-term care settings and less so in community- residing residents.
  • Wash your hands regularly with soap and water to reduce exposure to secretions.
  • Avoid being in close contact with sick people.
  • Sanitize commonly-touched objects like remote controls, phones and doorknobs when anyone in the house may have a URI.
  • Cover your mouth and nose if you are sick.
  • Stay home if you are sick.

Anti-Virals Neuraminidase Inhibitors

  • The recent H1N1 influenza pandemic increased interest in neuraminadase inhibitors in preventing and treating influenza. It is unclear whether data from use in seasonal influenza is applicable to pandemic situations. Two recent systematic reviews, based on evidence from prophylaxis (four trials), treatment (12 trials), and post-exposure prophylaxis (four trials), both concluded that these drugs did not result in meaningful symptomatic improvement in seasonal influenza.,
  • Whether oseltamivir reduces influenza-related LRTI complications remains unclear. The 2005 Cochrane systematic review concluded that it did. However, the most recent Cochrane review withdrew this conclusion on the basis that none of the original studies had been powered to detect differences in severe adverse events, and the authors had been unable to obtain trial data on complications from eight of 10 trials from an originally included meta-analysis

References

Muscle Spasms / Wasting; Types, Causes, Symptoms, Diagnosis, Treatment

Muscle Spasms / Wasting is a sudden and involuntary contraction of one or more of your muscles. If you’ve ever been awakened in the night or stopped in your tracks by a sudden charley horse, you know that muscle cramps can cause severe pain. Though generally harmless, muscle cramps can make it temporarily impossible to use the affected muscle.

Causes of Muscle Spasms / Wasting

  • Inadequate blood supply. Narrowing of the arteries that deliver blood to your legs (arteriosclerosis of the extremities) can produce cramp-like pain in your legs and feet while you’re exercising. These cramps usually go away soon after you stop exercising.
  • Nerve compression. Compression of nerves in your spine (lumbar stenosis) also can produce cramp-like pain in your legs. The pain usually worsens the longer you walk. Walking in a slightly flexed position — such as you would use when pushing a shopping cart ahead of you — may improve or delay the onset of your symptoms.
  • Mineral depletion. Too little potassium, calcium or magnesium in your diet can contribute to leg cramps. Diuretics — medications often prescribed for high blood pressure — also can deplete these minerals.
  • The muscles are trying to protect themselves from muscle strain 
    A back spasm can occur after any type of strain or injury to the soft tissues—the muscles, tendons or ligaments—in the spine. Following the general treatment guidelines below and the recommendations from your doctor or physical therapist will go a long way in relieving your pain, and your back muscles should calm down in a week or so.
  • The muscles can spasm in response to an underlying anatomical problem
    If your back spasm does not get better in 1 to 2 weeks, or it comes and goes over time in the same area of your back, you may have an underlying anatomical problem in your spine.

Details coming soon

Reference

Serum Lipid Profile; Normal Value, Causes, Treatment

Serum lipid profile or lipid panel is a panel of blood tests that serves as an initial broad medical screening tool for abnormalities in lipids, such as cholesterol and triglycerides. The results of this test can identify certain genetic diseases and can determine approximate risks for cardiovascular disease, certain forms of pancreatitis, and other diseases.

Cholesterol is carried through your blood, attached to proteins. This combination of proteins and cholesterol is called a lipoprotein. You may have heard of different types of cholesterol, based on what type of cholesterol the lipoprotein carries. They are-

Low-density lipoprotein (LDL)

LDL, or “bad,” cholesterol transports cholesterol particles throughout your body. LDL cholesterol builds up in the walls of your arteries, making them hard and narrow.

High-density lipoprotein (HDL)

HDL, or “good,” cholesterol picks up excess cholesterol and takes it back to your liver.

The lipid profile typically includes

  • Low-density lipoprotein (LDL)
  • High-density lipoprotein (HDL)
  • Triglycerides
  • Total cholesterol

Using these values, a laboratory may also calculate

  • Very low-density lipoprotein (VLDL)
  • Cholesterol:HDL ratio

The lipid profile tests are of 7 types

  • Total lipids
  • Serum total cholesterol
  • serum HDL cholesterol
  • Total cholesterol/HDL cholesterol ratio
  • Serum triglycerides
  • Serum Phospholipids
  • Electrophoretic fractionation to determination percentage of
    • (a) Chylomicrons
    • (b) LDL
    • (c) VLDL
    • (d) HDL

Normal Value

Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. Ideal results for most adults are:

  • LDL: 70 to 130 mg/dL (the lower the number, the better)
  • HDL: more than 40 to 60 mg/dL (the higher the number, the better)
  • total cholesterol: less than 200 mg/dL (the lower the number, the better)
  • triglycerides: 10 to 150 mg/dL (the lower the number, the better)

Or

Levels and ranges

In adults, total cholesterol levels less than 200 milligrams per deciliter (mg/dL) are considered healthy.

  • A reading between 200 and 239 mg/dL is borderline high.
  • A reading of 240 mg/dL and above is considered high.

LDL cholesterol levels should be less than 100 mg/dL.

  • 100–129 mg/dL is acceptable for people with no health problems but may be a concern for anyone with heart disease or heart disease risk factors.
  • 130—159 mg/dL is borderline high.
  • 160–189 mg/dL is high.
  • 190 mg/dL or higher is considered very high.

HDL levels should be kept higher. The optimal reading for HDL levels is of 60 mg/dL or higher.

  • A reading of less than 40 mg/dL is considered a major risk factor for heart disease.
  • A reading from 41 mg/dL to 59 mg/dL is borderline low.

Or

Serum triglyceride levels and classifications are as follows Less than 100 mg/dL – Optimal

  • 101-150 mg/dL – Normal
  • 150-199 mg/dL – Borderline
  • 200-499 mg/dL – High
  • 500 mg/dL or higher – Very high

Canadian and European guidelines differ slightly from U.S. guidelines. These conversions are based on U.S. guidelines.

Total cholesterol (U.S. and some other countries) Total cholesterol (Canada and most of Europe)
Below 200 mg/dL Below 5.2 mmol/L Desirable
200-239 mg/dL 5.2-6.2 mmol/L Borderline high
240 mg/dL and above Above 6.2 mmol/L High
LDL cholesterol (U.S. and some other countries) LDL cholesterol* (Canada and most of Europe)
Below 70 mg/dL Below 1.8 mmol/L Best for people who have heart disease or diabetes.
Below 100 mg/dL Below 2.6 mmol/L Optimal for people at risk of heart disease.
100-129 mg/dL 2.6-3.3 mmol/L Near optimal if there is no heart disease. High if there is heart disease.
130-159 mg/dL 3.4-4.1 mmol/L Borderline high if there is no heart disease. High if there is heart disease.
160-189 mg/dL 4.1-4.9 mmol/L High if there is no heart disease. Very high if there is heart disease.
190 mg/dL and above Above 4.9 mmol/L Very high
HDL cholesterol (U.S. and some other countries) HDL cholesterol* (Canada and most of Europe)
Below 40 mg/dL (men)
Below 50 mg/dL (women)
Below 1 mmol/L (men)
Below 1.3 mmol/L (women)
Poor
50-59 mg/dL 1.3-1.5 mmol/L Better
60 mg/dL and above Above 1.5 mmol/L Best
Triglycerides (U.S. and some other countries) Triglycerides (Canada and most of Europe)
Canadian and European guidelines differ slightly from U.S. guidelines. These conversions are based on U.S. guidelines.

Causes of Increasing  Lipid in Blood

Reasons you may not be able to have the test or why the results may not be helpful include:

  • Diabetes
  • Kidney disease
  • Polycystic ovary syndrome (PCOS)
  • Cushing’s syndrome
  • Metabolic syndrome
  •  Hypothyroidism
  • Lack of exercise – Not getting enough exercise can increase your LDL levels. Not only that, exercise has been shown to boost your healthy HDL levels.
  • Smoking – Smoking can also increase your bad cholesterol, causing plaque to build up in your arteries.
  • Genetics – If high cholesterol runs in your family, you’re at increased risk of having high cholesterol yourself.
  • Medicines, such as diuretics, corticosteroids, male sex hormones (androgens), tranquilizers, estrogen, birth control pills, antibiotics, and niacin (vitamin B3).
  • Physical stress, such as infection, heart attack, surgery.
  • Eating 9 to 12 hours before the test.
  • Other conditions, such as hypothyroidism, diabetes, or kidney or liver disease.
  • Alcohol or drug abuse or withdrawal.
  • Liver disease (such as cirrhosis or hepatitis), malnutrition, or hyperthyroidism.
  • Pregnancy.
  • Values are the highest during the third trimester and usually return to the prepregnancy levels after delivery of the baby.

Treatment of Serum Lipid Profile

A report from Harvard Health has identified “11 cholesterol lowering foods” that actively decrease cholesterol levels:

  • oats
  • barley and whole grains
  • beans
  • eggplant and okra
  • nuts
  • vegetable oil (canola, sunflower)
  • fruits (mainly apples, grapes, strawberries, and citrus)
  • soy and soy-based foods
  • fatty fish (particularly salmon, tuna, and sardines)
  • foods rich in fiber

Adding these to a balanced diet can help keep cholesterol in check. The same report also lists foods that are bad for cholesterol levels, including:

  • red meat
  • full-fat dairy
  • margarine
  • hydrogenated oils
  • baked goods

Lipid-lowering therapy

Drug treatment for an individual with hypercholesterolemia will depend on their cholesterol level and other risk factors. Diet and exercise are the first approaches used to reduce cholesterol levels. Statin treatment is normally prescribed for people with a higher risk of heart attack.

Statins are the leading group of cholesterol-lowering drugs; others include selective cholesterol absorption inhibitors, resins, fibrates, and niacin. The statins available on prescription in the United States include:

Side effects can include
  • statin-induced myopathy (a muscle tissue disease)
  • fatigue
  • a slightly greater risk of diabetes and diabetes complications, though this is hotly debated

Statins – Statins block a substance your liver needs to make cholesterol. This causes your liver to remove cholesterol from your blood. Statins may also help your body reabsorb cholesterol from built-up deposits on your artery walls, potentially reversing coronary artery disease. Choices include atorvastatin , fluvastatin , lovastatin (Altoprev), pitavastatin , pravastatin , rosuvastatin  and simvastatin .

Bile-acid-binding resins – Your liver uses cholesterol to make bile acids, a substance needed for digestion. The medications cholestyramine (Prevalite), colesevelam (Welchol) and colestipol (Colestid) lower cholesterol indirectly by binding to bile acids. This prompts your liver to use excess cholesterol to make more bile acids, which reduces the level of cholesterol in your blood.

Cholesterol absorption inhibitors – Your small intestine absorbs the cholesterol from your diet and releases it into your bloodstream. The drug ezetimibe (Zetia) helps reduce blood cholesterol by limiting the absorption of dietary cholesterol. Ezetimibe can be used in combination with a statin drug.

Injectable medications – A new class of drugs can help the liver absorb more LDL cholesterol — which lowers the amount of cholesterol circulating in your blood. Alirocumab (Praluent) and evolocumab (Repatha) may be used for people who have a genetic condition that causes very high levels of LDL or in people with a history of coronary disease who have intolerance to statins or other cholesterol medications.

Medications for High Triglycerides 

If you also have high triglycerides, your doctor may prescribe

Fibrates

The medications fenofibrate (TriCor, Fenoglide, others) and gemfibrozil (Lopid) decrease triglycerides by reducing your liver’s production of very-low-density lipoprotein (VLDL) cholesterol and by speeding up the removal of triglycerides from your blood. VLDL cholesterol contains mostly triglycerides.

Niacin

Niacin decreases triglycerides by limiting your liver’s ability to produce LDL and VLDL cholesterol. But niacin doesn’t provide any additional benefit than using statins alone. Niacin has also been linked to liver damage and stroke, so most doctors now recommend it only for people who can’t take statins.

Omega-3 fatty acid supplements 

Omega-3 fatty acid supplements can help lower your triglycerides. They are available by prescription or over-the-counter. If you choose to take over-the-counter supplements, get your doctor’s OK first. Omega-3 fatty acid supplements could affect other medications you’re taking.

References

 

 

RBS; Procedures, Normal Value, Causes, Symptoms

RBS (Random/High blood sugar)also spelled hyperglycemia or hyperglycæmia) is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/l (200 mg/dl), but symptoms may not start to become noticeable until even higher values such as 15–20 mmol/l (~250–300 mg/dl). A subject with a consistent range between ~5.6 and ~7 mmol/l (100–126 mg/dl) (American Diabetes Association guidelines) is considered slightly hyperglycemic, while above 7 mmol/l (126 mg/dl) is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person’s renal threshold of glucose and overall glucose tolerance. On average, however, chronic levels above 10–12 mmol/L (180–216 mg/dl) can produce noticeable organ damage over time.

Procedure of RBS 

  • A zero time (baseline) blood sample is drawn.
  • The patient is then given a measured dose (below) of glucose solution to drink within a 5-minute time frame.
  • Blood is drawn at intervals for measurement of glucose (blood sugar), and sometimes insulin levels. The intervals and number of samples vary according to the purpose of the test. For simple diabetes screening, the most important sample is the 2-hour sample and the 0 and 2-hour samples may be the only ones collected. A laboratory may continue to collect blood for up to 6 hours depending on the protocol requested by the physician.

The dose of glucose and variations of RBS 

  • 75g of an oral dose is the recommendation of the WHO to be used in all adults and is the main dosage used in the United States. The dose is adjusted for weight only in children. The dose should be drunk within 5 minutes.
  • A variant is often used in pregnancy to screen for gestational diabetes, with a screening test of 50 grams over one hour. If elevated, this is followed by a test of 100 grams over three hours.
  • In UK general practice, the standard glucose load was provided by 394ml of the energy drink Lucozade with original carbonated flavor, but this is being superseded by purpose-made drinks.
  • In Portugal, the standard glucose load is provided by the clinical laboratory or hospital by 200 ml of fluid in a PET bottle. The best-known brand is TopStar, produced in Portugal. The recommendation is for a 75g oral dose for all adults, which is adjusted for weight in children. However, doses of 50g and 100g are also used, available in orange, lemon and cola flavor.

Substances measured and variations of RBS 

If renal glycosuria (sugar excreted in the urine despite normal levels in the blood) is suspected, urine samples may also be collected for testing along with the fasting and 2-hour blood tests.

Results of RBS 

  • Fasting plasma glucose (measured before the OGTT begins) should be below 6.1 mmol/L (110 mg/dL). Fasting levels between 6.1 and 7.0 mmol/L (110 and 125 mg/dL) are borderline (“impaired fasting glycaemia”), and fasting levels repeatedly at or above 7.0 mmol/L (>126 mg/dL) are diagnostic of diabetes.
  • 1-hour GTT (Glucose Tolerance Test) glucose level below 10 mmol/L (180 mg/dL) is considered normal.
  • For a 2 hour GTT (Glucose Tolerance Test) with 75g intake, a glucose level below 7.8 mmol/L (140 mg/dL) is normal, whereas higher glucose levels indicate hyperglycemia. Blood plasma glucose between 7.8 mmol/L (140 mg/dL) and 11.1 mmol/L (200 mg/dL) indicate “impaired glucose tolerance”, and levels above 11.1 mmol/L (200 mg/dL) at 2 hours confirm a diagnosis of diabetes.

For gestational diabetes, the American College of Obstetricians and Gynecologists (ACOG) recommends a two-step procedure, wherein the first step is a 50g glucose dose. If it results in a blood glucose level of more than 7.8 mmol/L (140 mg/dL), it is followed by a 100-gram glucose dose. The diagnosis of gestational diabetes is then defined by a blood glucose level exceeding the cutoff value on at least two intervals, with cutoffs as follows

  • Before glucose intake (fasting): 5.3 mmol/L (95 mg/dL)
  • 1 hour after drinking the glucose solution: 10 mmol/L (180 mg/dL)
  • 2 hours: 8.6 mmol/L (155 mg/dL)
  • 3 hours: 7.8 mmol/L (140 mg/dL)
NICE recommended target blood glucose level ranges
Target Levels
by Type
Upon waking Before meals
(preprandial)
At least 90 minutes after meals
(postprandial)
Non-diabetic* 4.0 to 5.9 mmol/L under 7.8 mmol/L
Type 2 diabetes 4 to 7 mmol/L under 8.5 mmol/L
Type 1 diabetes 5 to 7 mmol/L 4 to 7 mmol/L 5 to 9 mmol/L
Children w/ type 1 diabetes 4 to 7 mmol/L 4 to 7 mmol/L 5 to 9 mmol/L

*The non-diabetic figures are provided for information but are not part of NICE guidelines.

Normal and diabetic blood sugar ranges

For the majority of healthy individuals, normal blood sugar levels are as follows:

  • Between 4.0 to 6.0 mmol/L (72 to 108 mg/dL) when fasting
  • Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating

For people with diabetes, blood sugar level targets are as follows:

  • Before meals: 4 to 7 mmol/L for people with type 1 or type 2 diabetes
  • After meals: under 9 mmol/L for people with type 1 diabetes and under 8.5mmol/L for people with type 2 diabetes

Blood sugar levels in diagnosing diabetes

The following table lays out criteria for diagnoses of diabetes and prediabetes.

Blood sugar levels in diagnosing diabetes
Plasma glucose test Normal Prediabetes Diabetes
Random Below 11.1 mmol/l
Below 200 mg/dl
N/A 11.1 mmol/l or more
200 mg/dl or more
Fasting Below 6.1 mmol/l
Below 108 mg/dl
6.1 to 6.9 mmol/l
108 to 125 mg/dl
7.0 mmol/l or more
126 mg/dl or more
2 hour post-prandial Below 7.8 mmol/l
Below 140 mg/dl
7.8 to 11.0 mmol/l
140 to 199 mg/dl
11.1 mmol/l or more
200 mg/dl or more

Causes of Random/high Blood Suger

Sometimes, hyperglycemia is not the result of diabetes. Other medical conditions that can cause hyperglycemia include:

  • Pancreatitis (inflammation of the pancreas)
  • Pancreatic cancer
  • Hyperthyroidism (overactive thyroid gland)
  • Cushing’s syndrome (elevated blood cortisol level)
  • Unusual tumors that secrete hormones, including glucagonoma, pheochromocytoma, or growth hormone-secreting tumors
  • Severe stresses on the body, such as heart attack, stroke, trauma, or severe illnesses, can temporarily lead to hyperglycemia
  • Taking certain medications, including prednisone, estrogens, beta-blockers, glucagon, oral contraceptives, phenothiazines, and others, can elevate blood glucose levels
Causes of abnormal glucose levels
Persistent hyperglycemia Transient hyperglycemia Persistent hypoglycemia Transient hypoglycemia
Reference range, FBG: 70–110 mg/dL
Diabetes mellitus Pheochromocytoma Insulinoma Acute alcohol ingestion
Adrenal cortical hyperactivity Cushing’s syndrome Severe liver disease Adrenal cortical insufficiency Addison’s disease Drugs: salicylates, antituberculosis agents
Hyperthyroidism Acute stress reaction Hypopituitarism Severe liver disease
Acromegaly Shock Galactosemia Several glycogen storage diseases
Obesity Convulsions Ectopic insulin production from tumors Hereditary fructose intolerance

High Blood Sugar Symptoms

Common symptoms can include:

Treatment of RBS

Management of type 2 diabetes includes:

  • Healthy eating
  • Regular exercise
  • Possibly, diabetes medication or insulin therapy
  • Blood sugar monitoring

Healthy eating

Contrary to popular perception, there’s no specific diabetes diet. However, it’s important to center your diet on these high-fiber, low-fat foods:

  • Fruits
  • Vegetables
  • Whole grains
  • You’ll also need to eat fewer animal products, refined carbohydrates and sweets.

Physical activity

  • Everyone needs regular aerobic exercise, and people who have type 2 diabetes are no exception. Get your doctor’s OK before you start an exercise program. Then choose activities you enjoy, such as walking, swimming and biking. What’s most important is making physical activity part of your daily routine.
  • Aim for at least 30 minutes of aerobic exercise five days of the week. Stretching and strength training exercises are important, too. If you haven’t been active for a while, start slowly and build up gradually.

A combination of exercises 

  • Aerobic exercises, such as walking or dancing on most days, combined with resistance training, such as weightlifting or yoga twice a week — often helps control blood sugar more effectively than either type of exercise alone.

Monitoring your blood sugar

  • Depending on your treatment plan, you may need to check and record your blood sugar level every now and then or, if you’re on insulin, multiple times a day. Ask your doctor how often he or she wants you to check your blood sugar. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range.

Diabetes medications and insulin therapy

  • Some people who have type 2 diabetes can achieve their target blood sugar levels with diet and exercise alone, but many also need diabetes medications or insulin therapy. The decision about which medications are best depends on many factors, including your blood sugar level and any other health problems you have. Your doctor might even combine drugs from different classes to help you control your blood sugar in several different ways.

Examples of possible treatments for type 2 diabetes include

Metformin (Glucophage, Glumetza, others)

  • Generally, metformin is the first medication prescribed for type 2 diabetes. It works by improving the sensitivity of your body tissues to insulin so that your body uses insulin more effectively.
  • Metformin also lowers glucose production in the liver. Metformin may not lower blood sugar enough on its own. Your doctor will also recommend lifestyle changes, such as losing weight and becoming more active.

Sulfonylureas

  • These medications help your body secrete more insulin. Examples of medications in this class include glyburide, glipizide, and glimepiride. Possible side effects include low blood sugar and weight gain.

Meglitinides 

  • These medications work like sulfonylureas by stimulating the pancreas to secrete more insulin, but they’re faster acting, and the duration of their effect in the body is shorter. They also have a risk of causing low blood sugar, but this risk is lower than with sulfonylureas.

Thiazolidinediones

  • Like metformin, these medications make the body’s tissues more sensitive to insulin. This class of medications has been linked to weight gain and other more-serious side effects, such as an increased risk of heart failure and fractures. Because of these risks, these medications generally aren’t a first-choice treatment.

DPP-4 inhibitors

  • These medications help reduce blood sugar levels, but tend to have a modest effect. They don’t cause weight gain. Examples of these medications are sitagliptin , saxagliptin  and linagliptin .

GLP-1 receptor agonists

  • These medications slow digestion and help lower blood sugar levels, though not as much as sulfonylureas. Their use is often associated with some weight loss. This class of medications isn’t recommended for use by itself

SGLT2 inhibitors

  • These are the newest diabetes drugs on the market. They work by preventing the kidneys from reabsorbing sugar into the blood. Instead, the sugar is excreted in the urine.

Insulin therapy 

  • Some people who have type 2 diabetes need insulin therapy as well. In the past, insulin therapy was used as a last resort, but today it’s often prescribed sooner because of its benefits.

References

 

X-Ray; Types, Indications, Procedures, Adverse Effects

X-Ray is a form of electromagnetic radiation with very high frequency and energy. X-rays lie between ultraviolet radiation and gamma radiation on the electromagnetic spectrum. A bone x-ray uses a very small dose of ionizing radiation to produce pictures of any bone in the body. It is commonly used to diagnose fractured bones or joint dislocation. Bone x-rays are the fastest and easiest way for your doctor to view and assess bone fractures, injuries, and joint abnormalities.

Chest x-ray (frontal view)

  • Lateral CXR rarely indicated and should be discussed with a consultant
  • Pre-operative CXR NOT to be done routinely at any age.

Respiratory indications

  • Infection – to exclude pneumonia
  • Inhaled foreign body >most lodge in the intrathoracic tracheobronchial tree.
  • Need films in full inspiration and expiration to demonstrate air trapping or collapse.
Chest trauma
  • for an air leak, haemothorax or wide mediastinum.
  • Rib views rarely indicated.
  • Pneumothorax – full inspiratory films adequate
Asthma/ Bronchiolitis – Consider only if
  • diagnosis unclear
  • SEVERE attack – not responding to standard therapy
    possible air leak.
  • NB. Focal signs +/- fever is most likely due to mucus plug and viral illness rather than pneumonia.

Cardiac indications

Clinical cardiomegaly or heart failure.
  • Large thymic shadow is normal under the age of 2 years.
  • Normal cardio-thoracic ratio 0.5 ( infants up to 0.6 )
  • Heart murmurs – If careful examination suggests innocent murmur, no need for urgent CXR – but arrange appropriate follow up.
  • Hypertension – CXR is seldom useful.

Neonates (<6wks)

  • Septic screen – CXR indicated unless clear focus elsewhere
  • Respiratory distress – to exclude congestive cardiac failure or cardiomegaly

Limb x-rays & other imaging modalities

Comparative and Stress Views – rarely necessary and should not be routinely taken. However may be useful for complex fractures (after consultation) if initial x-rays unclear (eg. elbow)

Specific Indications/Contraindications:

Trauma

Xray of the suspected fracture as well as the joints above and below if signs and symptoms suggest bone injury.  If in doubt about the site of injury, seek senior help rather than x-raying the entire limb.
  • Follow up films after reduction of a displaced # should be done to assess the position.
If a fracture is clinically suspected but x-rays normal, discuss with the consultant and if in doubt treat as if fracture present.
  • Additional views are sometimes useful (eg. radial head views) and other fractures (eg. stress # or toddler #) might need Bone Scan or CT (these requests should be discussed with ED consultant & orthopedics and appropriate follow-up arranged).

Nonaccidental injury (to be seen by registrar or consultant)

  • If child > 2yr x-rays should be limited to sites of clinically suspected injury.
  • Complete Skeletal Survey if child < 3 years (not available after-hours unless urgent)
  • Bone Scan (if < 3yr) – can complement skeletal survey
Suspect NAI if:
  • metaphyseal
  • marked or unusual epiphyseal separation
  • of spine or ribs
  • unexplained skull  intracranial- injury

Acutely painful hip

  • Plain xrays (AP and frog-leg lateral) will demonstrate slipped upper femoral epiphyses, Perthe’s and fractures.
  • USS/ bone scan may be indicated depending on clinical findings (discuss with specialty team or treating consultant).

Acutely swollen joint

Osteomyelitis

  • Early XR often shows no bony abnormality but may have deep soft tissue swelling.
  • Bone scan/MRI will demonstrate an abnormality earlier than XR (needs orthopedic team input)

Septic Arthritis

  • Normal XR or Bone scan does not exclude septic arthritis.
  • Ultrasound may be useful to demonstrate a joint effusion and soft tissue abnormality (discuss with orthopedic team or treating consultant)

Metabolic disorders

  • Rickets – XR of one wrist +/- one knee is most useful.
  • Osteogenesis Imperfecta – the very low threshold for an x-ray.

Pulled Elbow

  • If the injury mechanism and examination suggest radial head subluxation, an x-ray is unnecessary.

Abdominal x- rays

Suspected bowel obstruction/ perforation

  • A plain AXR will demonstrate most obstruction (dilated loops).
  • An erect AXR is indicated to exclude perforation

 Suspected intussusception

  • A normal AXR does not exclude intussusception but is useful to exclude perforation or bowel obstruction in suspected intussusception.

Foreign Bodies

  • Ingested opaque FB requires a single survey AP film (mouth to anus).
  • Routine follow-up films are NOT indicated unless clinical symptoms develop.

Suspected Abdominal Mass

  • Initial investigation – plain AXR and ultrasound, then further as indicated

Blunt abdominal trauma

  • Needs early assessment by General Surgery.
  • CT scan is the best modality for diagnosing the intra-abdominal injury.

Unnecessary AXRs

If unsure whether AXR would be helpful – ask consultant or registrar for advice

AXR not indicated for:

  • Vague central abdominal pain.
  • Gastroenteritis.
  • Haematemesis.
  • Pyloric stenosis.
  • Uncomplicated appendicitis.
  • Chronic constipation, encopresis or enuresis (in the Emerg. Dept setting )

Abdominal & pelvic ultrasounds

If an urgent ultrasound is necessary, the patient should be discussed with the surgeon &/or the treating consultant.

Specific indications

Suspected intussusception

  • Ultrasound by experienced operators is the diagnostic modality of choice for intussusception.
  • However these patients are potentially unstable and should only be sent for an ultrasound after appropriate resuscitation including an IV,  and treatment as well as notifying the surgeons and the treating consultants

Suspected pyloric stenosis

  • Ultrasound is a very sensitive test for pyloric stenosis

Abdominal pain

  • or iliac or pelvic pain in the pubertal female with possible ovarian pathology (requires full bladder), or if potential renal tract obstruction, early ultrasound recommended.
  • Abdominal ultrasound is a useful tool for many other abdominal pain presentations however the urgency of the request should be proportional to the symptoms.

Urinary tract imaging

  • Bacteriologically proved first UTI usually requires renal tract US (particularly <4 years old) but only occasionally MCU

Intracranial and skull imaging

Specific Indications for Skull X-rays

Only indicated in well-appearing children

NAI

  •  as part of the skeletal survey (more sensitive than Bone Scan for skull fracture)

Plagiocephaly

  • Craniosynostosis (prematurely fused sutures) accounts for the minority of abnormal skull shapes. An SXR is useful to evaluate sutures but is ideally done via outpatient follow-up (Craniofacial or neurosurgical unit- RCH Deformational head clinic)

There are no other routine indications for skull XRay and any such requests should be discussed with the treating consultant.

Specific Indications for CT Brain

  • The treating consultant should discuss the need for all CT scans.
  • The Neurosurgical team should be involved before CT for the unwell or potentially unstable patient who may need urgent interventions.

Head Trauma

  • Useful for rapid diagnosis of suspected intracranial injuries and is the preferred investigation if clinical evidence of intracranial injury.
  • Clinical deterioration is usually an indication for repeat CT examination.

Depressed conscious level of unknown cause

  • CT scan is indicated after appropriate stabilizing treatment.

Headaches

Clinical evaluation is the most important factor in determining the need for imaging.

CT scan indications

  • Abnormal neurological signs.
  • Unexplained decrease in visual acuity.
  • Headaches with seizures.
  • Marked change in behavior.
  • Enlarging head
  • Symptoms of raised intracranial pressure.
  • The increasing frequency of unexplained headaches or new onset of a severe or persistent headache

Seizures

  • Persistent abnormal neurological signs/impaired conscious state.
  • Focal neurological signs or EEG findings.
  • Failure to respond to anticonvulsant therapy.
  • Neurocutaneous lesions.

Abnormal Size / Shape Of Skull

Clinical examination is usually sufficient to diagnose an abnormality of the skull.

  • Large head – rapidly enlarging head needs imaging-US or CT scan.
  • Small head – nearly always pathological secondary to abnormal brain growth. Evaluate with CT or MRI scan, which is usually best organized via the managing outpatient physician

Specific Indications for cranial ultrasound

Large head

  • Rapidly enlarging head with open fontanelle.

Neurological concerns in neonates/ infants

  • Clinical usefulness will vary depending on the size of fontanelle and indications and should be discussed with the radiologist.

Spinal imaging

Any investigations other than plain x- rays should be ordered in consultation with the treating consultant &/or the appropriate specialty team.

NB. Down syndrome children have increased the risk of C1-2 instability.

Specific indications in Trauma:

Cervical spine

A normal Spinal Xray series or CT scan will not allow clearance of the neck in the unconscious or uncooperative patient

Thoraco-Lumbar Spine

  • Children poorly localize the level of the injury, therefore imaging the full length of thora columbar spine may be necessary (discuss with treating consultant).
  • If neurological signs present do a CT or MRI scan after consultation with Neurosurgery.

Specific Non-trauma indications:

Scoliosis

  • Plain films should include the entire spine

Potential cord compression

  • Needs discussion with the treating consultant and neurosurgical team.

Suspected focal vertebral pathology

  • Choice of imaging modality needs discussion with the treating consultant.

References

Urine Analysis / Urinalysis

Incomplete Spinal Cord Injury; Diagnosis, Treatment

Incomplete spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion. The most common causes of SCI in the world are traffic accidents, gunshot injuries, knife injuries, falls and sports injuries. There is a strong relationship between functional status and whether the injury is complete or not complete, as well as the level of the injury. The results of SCI bring not only damage to independence and physical function, but also include many complications from the injury. Neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders are frequent complications after SCI. SCI leads to serious disability in the patient resulting in the loss of work, which brings psychosocial and economic problems. The treatment and rehabilitation period is long, expensive and exhausting in SCI. Whether complete or incomplete, SCI rehabilitation is a long process that requires patience and motivation of the patient and relatives. Early rehabilitation is important to prevent joint contractures and the loss of muscle strength, conservation of bone density, and to ensure normal functioning of the respiratory and digestive system. An interdisciplinary approach is essential in rehabilitation in SCI, as in the other types of rehabilitation. The team is led by a physiatrist and consists of the patients’ family, physiotherapist, occupational therapist, dietician, psychologist, speech therapist, social worker and other consultant specialists as necessary.

 

rx

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Spinal Cord Injury Anatomy: The Basics

Though you might think of your spinal cord as one single piece, it’s actually a column of nerves protected by a sheath of myelin and then further secured by 31 butterfly-shaped vertebrae (singular: vertebra).

Medical providers divide the spinal cord into four distinct regions. Knowing the region in which the injury is located is often the key to understanding diagnosis and treatment. The four spinal cord regions are:

  • The cervical spinal cord This is the topmost portion of the spinal cord, where the brain connects to the spinal cord, and the neck connects to the back. This region consists of eight vertebrae, commonly referred to as C1-C8. All spinal cord numbers are descending, so C1 is the highest vertebra, while C8 is the lowest in this region.
  • The thoracic spinal cord This section forms the middle of the spinal cord, containing twelve vertebrae numbered T1-T12.
  • The lumbar spinal cord This is a lower region of the spinal cord, where your spinal cord begins to bend. If you put your hand in your lower back, where your back bends inward, you’re feeling your lumbar region. There are five lumbar vertebrae, numbered L1-L5.
  • The sacral spine This is the lower, triangle-shaped region of the spine, also with five vertebrae. While the lumbar cord bends inward, the vertebrae of the sacral region bend slightly outward. There is no actual spinal cord in this section, it is made up of nerve roots which exit the spine at their respective vertebral levels.
  • The coccygeal region – sometimes known as the coccyx or tail bone, consists of a single vertebra at the very base of the spinal cord.

Causes of Spinal Cord Injuries

Spinal cord injuries occur for many different reasons. Depending upon the severity of the injury, patient’s symptoms may be mild, moderate, or severe enough to cause death. Spinal cord injuries should be treated as quickly as possible to avoid further damage. Some patients may experience temporary symptoms while others will be left with lifelong symptoms.

Causes for spinal cord injuries are characterized as ‘traumatic’ or ‘non-traumatic.’ Traumatic injuries are caused by an abrupt traumatic hit to the spine which results in damage to one or more of the vertebrae, or a severing of the spinal cord. Non-traumatic injuries are the result of slow internal damage to the spinal cord region.

Traumatic spinal cord injuries occur due to

  • Motor vehicle accidents (Motor vehicle accidents (38%)-Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than 35 percent of new spinal cord injuries each year.
  • Falls ,Slips/falls (30.5%)- Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause more than one-quarter of spinal cord injuries.
  • Acts of violence,Acts of violence (13.5%)- Around 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds, according to the National Spinal Cord Injury Statistical Center.
  • Sports and recreation injuries,Sports-related injuries (9%)- Athletic activities, such as impact sports and diving in shallow water, cause about 9 percent of spinal cord injuries.
  • Alcohol,Medical / surgical (5%)- Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
  • Diseases,Other (4%)- Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Non-traumatic spinal cord injuries occur due to

Level of Spinal Cord Injury…………………………………. 

Vertebrae are grouped into sections. The higher the injury on the spinal cord, the more dysfunction can occur.

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High-Cervical Nerves (C1 – C4)

  • Most severe of the spinal cord injury levels
  • Paralysis in arms, hands, trunk and legs
  • Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements.
  • Ability to speak is sometimes impaired or reduced.
  • When all four limbs are affected, this is called tetraplegia or quadriplegia.
  • Requires complete assistance with activities of daily living, such as eating, dressing, bathing, and getting in or out of bed
  • May be able to use powered wheelchairs with special controls to move around on their own
  • Will not be able to drive a car on their own
  • Requires 24-hour-a-day personal care

Low-Cervical Nerves (C5 – C8)

  • Corresponding nerves control arms and hands.
  • A person with this level of injury may be able to breathe on their own and speak normally.
C5 injury
  • Person can raise his or her arms and bend elbows.
  • Likely to have some or total paralysis of wrists, hands, trunk and legs
  • Can speak and use diaphragm, but breathing will be weakened
  • Will need assistance with most activities of daily living, but once in a power wheelchair, can move from one place to another independently.
C6 injury
  • Nerves affect wrist extension.
  • Paralysis in hands, trunk and legs, typically
  • Should be able to bend wrists back
  • Can speak and use diaphragm, but breathing will be weakened
  • Can move in and out of wheelchair and bed with assistive equipment
  • May also be able to drive an adapted vehicle
  • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment
C7 injury
  • Nerves control elbow extension and some finger extension.
  • Most can straighten their arm and have normal movement of their shoulders.
  • Can do most activities of daily living by themselves, but may need assistance with more difficult tasks
  • May also be able to drive an adapted vehicle
  • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment.
C8 injury
  • Nerves control some hand movement.
  • Should be able to grasp and release objects
  • Can do most activities of daily living by themselves, but may need assistance with more difficult tasks
  • May also be able to drive an adapted vehicle
  • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment
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Thoracic vertebrae are located in the mid-back.

Thoracic Nerves (T1 – T5)

  • Corresponding nerves affect muscles, upper chest, mid-back and abdominal muscles.
  • Arm and hand function is usually normal.
  • Injuries usually affect the trunk and legs(also known as paraplegia).
  • Most likely use a manual wheelchair
  • Can learn to drive a modified car
  • Can stand in a standing frame, while others may walk with braces

Thoracic Nerves (T6 – T12)

  • Nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury.
  • Usually results in paraplegia
  • Normal upper-body movement
  • Fair to good ability to control and balance trunk while in the seated position
  • Should be able to cough productively (if abdominal muscles are intact)
  • Little or no voluntary control of bowel or bladder but can manage on their own with special equipment
  • Most likely use a manual wheelchair
  • Can learn to drive a modified car
  • Some can stand in a standing frame, while others may walk with braces.
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Lumbar Nerves (L1 – L5)

  • Injuries generally result in some loss of function in the hips and legs.
  • Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment
  • Depending on strength in the legs, may need a wheelchair and may also walk with braces

Sacral Nerves (S1 – S5)

  • Injuries generally result in some loss of functionin the hips and legs.
  • Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment
  • Most likely will be able to walk

 Symptoms of an acute spinal cord injury

Symptoms vary depending on the severity and location of the SCI. At first, the patient may experience spinal shock, which causes loss of feeling, muscle movement, and reflexes below the level of injury. Spinal shock usually lasts from several hours to several weeks. As the period of shock lessens, other symptoms appear, depending on the location of the injury.

Generally, the higher up the level of the injury to the spinal cord, the more severe the symptoms. For example, an injury at C2 or C3 (the second and third vertebrae in the spinal column), affects the respiratory muscles and the ability to breathe. A lower injury, in the lumbar vertebrae, may affect nerve and muscle control to the bladder, bowel, and legs.

SCI is classified according to the person’s type of loss of motor and sensory function. The following are the main types of classifications:

  • Quadriplegia (quad means four). This involves loss of movement and sensation in all four limbs (arms and legs). It usually happens as a result of injury at T1 or above. Quadriplegia also affects the chest muscles and injuries at C4 or above require a mechanical breathing machine (ventilator).
  • Paraplegia (para means two like parts). This involves loss of movement and sensation in the lower half of the body (right and left legs). It usually happens as a result of injuries at T1 or below.
  • Triplegia (tri means three). This involves the loss of movement and sensation in one arm and both legs and usually results from incomplete SCI.
    Level Motor Function
    C1–C6 Neck flexors
    C1–T1 Neck extensors
    C3, C4, C5 Supply diaphragm (mostly C4)
    C5, C6 Move shoulder, raise arm(deltoid); flex elbow (biceps)
    C6 externally rotate (supinate) the arm
    C6, C7 Extend elbow and wrist (triceps and wrist extensors); pronatewrist
    C7, T1 Flex wrist; supply small muscles of the hand
    T1–T6 Intercostals and trunk above the waist
    T7–L1 Abdominal muscles
    L1–L4 Flex thigh
    L2, L3, L4 Adduct thigh; Extend leg at the knee (quadriceps femoris)
    L4, L5, S1 abduct thigh; Flex leg at the knee (hamstrings); Dorsiflexfoot (tibialis anterior); Extend toes
    L5, S1, S2 Extend leg at the hip (gluteus maximus); Plantar flex foot and flex toes

The following are the most common symptoms of acute spinal cord injuries. However, each individual may experience symptoms differently. Symptoms may include:

  • Muscle weakness or paralysis in the trunk, arms or legs
  • Loss of feeling in the trunk, arms, or legs
  • Muscle spasticity
  • Breathing problems
  • Problems with heart rate and blood pressure
  • Digestive problems
  • Loss of bowel and bladder function
  • Bedsores
  • Chronic pain
  • Headaches
  • Changes in mood or personality
  • Loss of libido or sexual function
  • Loss of fertility
  • Nerve pain
  • Chronic muscle pain
  • Pneumonia (more than half of cervical spinal cord injury survivors struggle with bouts of pneumonia)
  • Sexual dysfunction
  • Loss of movement
  • Loss of sensation, including the ability to feel heat, cold and touch
  • Loss of bowel or bladder control
  • Exaggerated reflex activities or spasms
  • Changes in sexual function, sexual sensitivity and fertility
  • Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
  • Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms

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

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

The symptoms of SCI may resemble other medical conditions or problems. Always talk with your healthcare provider for a diagnosis.

Types of Spinal Cord Injuries

All spinal cord injuries are divided into two broad categories: incomplete and complete.

  • Incomplete spinal cord injuries: With incomplete injuries, the cord is only partially severed, allowing the injured person to retain some function. In these cases, the degree of function depends on the extent of the injuries.
  • Complete spinal cord injuries: By contrast, complete injuries occur when the spinal cord is fully severed, eliminating function. Though, with treatment and physical therapy, it may be possible to regain some function.

Knowing the location of your injury and whether or not the injury is complete can help you begin researching your prognosis and asking your doctor intelligent questions. Doctors assign different labels to spinal cord injuries depending upon the nature of those injuries. The most common types of spinal cord injuries include:

  • Tetraplegia: These injuries, which are the result of damage to the cervical spinal cord, are typically the most severe, producing varying degrees of paralysis of all limbs. Sometimes known as quadriplegia, tetraplegia eliminates your ability to move below the site of the injury, and may produce difficulties with bladder and bowel control, respiration, and other routine functions. The higher up on the cervical spinal cord the injury is, the more severe symptoms will likely be.
  • Paraplegia: This occurs when sensation and movement are removed from the lower half of the body, including the legs. These injuries are the product of damage to the thoracic spinal cord. As with cervical spinal cord injuries, injuries are typically more severe when they are closer to the top vertebra.
  • Triplegia: Triplegia causes loss of sensation and movement in one arm and both legs, and is typically the product of an incomplete spinal cord injury.

Injuries below the lumbar spinal cord do not typically produce symptoms of paralysis or loss of sensation. They can, however, produce nerve pain, reduce function in some areas of the body, and necessitate several surgeries to regain function. Injuries to the sacral spinal cord, for instance, can interfere with bowel and bladder function, cause sexual problems, and produce weakness in the hips or legs. In very rare cases, sacral spinal cord injury survivors suffer temporary or partial paralysis.

Types of Incomplete Spinal Cord Injuries

Muscle strength ASIA Impairment Scale for classifying spinal cord injury
Grade Muscle function Grade Description
0 No muscle contraction A Complete injury. No motor or sensory function is preserved in the sacral segments S4 or S5.
1 Muscle flickers B Sensory incomplete. Sensory but not motor function is preserved below the level of injury, including the sacral segments.
2 Full range of motion, gravity eliminated C Motor incomplete. Motor function is preserved below the level of injury, and more than half of muscles tested below the level of injury have a muscle grade less than 3 (see muscle strength scores, left).
3 Full range of motion, against gravity D Motor incomplete. Motor function is preserved below the level of injury and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
4 Full range of motion against resistance E Normal. No motor or sensory deficits, but deficits existed in the past.
5 Normal strength

Knowing that a spinal cord injury is “incomplete” isn’t in and of itself enough to know the severity of the injury. Incomplete injuries manifest in myriad ways. Some of the most common include

The American Spinal Injury Association/International Spinal Cord Society Neurological Standard Scale (Better known as the “ASIA Impairment Scale”)
ASIA Impairment Scale Lesion
A
  • No motor or sensory function is preserved in the sacral segments S4–S5
Complete
B
  • Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4–S5
Incomplete
C
  • Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3
Incomplete
D
  • Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more
Incomplete
E
  • Motor and sensory functions are normal
Normal
The Frankel Scale for Spinal Cord Injury That Classifies the Extent of the Neurological/Functional Deficit into Five Grades
Frankel Scale
A
  • Complete
No motor or sensory function below the level of the lesion
B
  • Sensory only
No motor function, but some sensation preserved below the level of the lesion
C
  • Motor useless
Some motor function without practical application
D
  • Motor useful
The useful motor function below the level of the lesion
E
  • Recovery
Normal motor and sensory function may have reflex abnormalities

Anterior cord syndrome: causes injury to the front of the spinal cord, interfering with sensations of touch, pain, and temperature. Most anterior cord injury survivors can recover some movement.

A condition characterized by

  • motor dysfunction
  • dissociated sensory deficit below level of SCI

Pathophysiology

  • injury to anterior spinal cord caused by direct compression (osseous) of the anterior spinal cord anterior spinal artery injury anterior 2/3 spinal cord supplied  by the anterior spinal artery

Mechanism

  • Usually, result of flexion/ compression injury
  • Examination of lower extremity affected more than upper extremityloss >LCT (motor) >LST (pain, temperature)preserved >DC (proprioception, vibratory sense)

Prognosis

  • worst prognosis of incomplete SCI
  • most likely to mimic complete cord syndrome
  • 10-20% chance of motor recovery

Posterior cord syndrome: causes injuries to the back of the spinal cord. Most posterior injury survivors maintain good posture and muscle tone, as well as some movement but struggle with poor coordination.

  • Introduction very rare loss proprioception preserved motor, pain, light touch

Central cord syndrome: This injury is an injury to the center of the cord, and damages nerves that carry signals from the brain to the spinal cord. Loss of fine motor skills, paralysis of the arms, and partial impairment—usually less pronounced—in the legs are common. Some survivors also suffer a loss of bowel or bladder control, or lose the ability to sexually function.

diagram of vertebrae and spinal nerves

Epidemiology

  • incidence >the most common incomplete cord injury  
  • demographics >often in elderly with minor extension injury mechanisms due to anterior osteophytes and posterior infolded ligament flavum

Pathophysiology

  • believed to be caused by spinal cord compression and central cord edema with selective destruction of lateral corticospinal tract white matter
  • anatomy of spinal cord explains why upper extremities and hand preferentially affected hands and upper extremities are located “centrally” in corticospinal tract

Presentation

  • symptoms of weakness with hand dexterity most affected, hyperpathia, burning in distal upper extremity
  • physical exam > loss of motor deficit worse in UE than LE (some preserved motor function) hands have more pronounced motor deficit than arms preserved, sacral sparing

Late clinical presentation

  • UE have LMN signs (clumsy)
  • LE has UMN signs (spastic)

Treatment

  • nonoperative vs. operative extremely controversial

Prognosis

Final outcome  good prognosis although full functional recovery rare

  • Usually ambulatory at final follow up
  • Usually, regain bladder control
  • Upper extremity and hand recovery is unpredictable and patients often have permanent clumsy hands recovery occurs in the typical pattern of lower extremity recovers first, bowel and bladder function next, proximal upper extremity next, hand function last to recover

Brown-Sequard syndrome: This variety of injury is the product of damage to one side of the spinal cord. The injury may be more pronounced on one side of the body; for instance, the movement may be impossible on the right side but may be fully retained on the left. The degree to which Brown-Sequard patients are injured greatly varies from patient to patient.

  • Caused by complete cord hemi transection usually seen with penetrating trauma

Examipsilateral deficit

LCS tract > motor function >dorsal columns

  • proprioception
  • vibratory sense

Contralateral deficit

  • LST> pain, temperature, spinothalamic tracts cross at spinal cord level (classically 2-levels below)
  • Prognosis of excellent prognosis 99% ambulatory at final follow up, the best prognosis for function motor activity
  • Cauda equina lesion: damages the nerves between the first and second lumbar regions of the spine, resulting in a loss of sensation, but not a loss of movement. It may be possible to repair or regenerate some nerves to improve function.

Treatment Spinal  Cord Injury

Non-surgical

  • Rest – It is important that patient take proper rest and sleep and avoid any activities which will further aggravate the disc bulge and its symptoms. Many minor disc bulges can heal on their own with rest and other conservative treatment.
  • Cervical Pillow – It is important to use the right pillow to give your neck the right type of support for healing from a cervical disc bulge and also to improve the quality of sleep.

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Specific treatment for lumbar disk disease will be determined by your health care provider based on

  • Your age, overall health, and medical history
  • Extent of the condition
  • Type of condition
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Typically, conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.

  • Ice & Moist Heat Application

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Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provide the same benefit.

  • Hot Bath

Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.

  • Traction

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  • Massage therapy – may give short-term pain relief, but not a functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • “Back school” –  is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
  • Patient education on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
  • Physical therapy – which may include ultrasound, massage, conditioning, and exercise
  • Weight control
  • Use of a lumbosacral back support

Medications for Spinal Cord Injury

  • Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
  • Antidepressants: A Drugs that block pain messages from your brain and boost the effects of eorphins (your body’s natural painkillers).
  • Medication – Common pain remedies such as aspirinacetaminophen, ibuprofen , and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications,including muscle relaxants and anti-seizure medications, treat aspects of spinal stenosis, such as muscle spasms and damaged nerves.
  • Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
  • Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time.
  • Muscle Relaxants – These medications provide relief from spinal muscle spasms.
  • Skeletal muscle relaxers –  may also be used.Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects.
  • Neuropathic Agents: Drugs(pregabalin & gabapentine) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
  • Antibiotic –  to the management of bowel & bladders control and protect further infection. Infection causes should be treated with appropriate antibiotic therapy
  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • Calcium & vitamin D3 – to improve bones health and healing fracture.
  • Glucosamaine & diacerine – can be used to tightening the loose tenson and regenerate cartilage or inhabit the further degeneration of cartilage.
  • Corticosteroid – to healing the nerve inflamation and clotted blood in the  joints.
  • Diatery suppliment -to remove the general weakness & improved the health.
  • Lesion debulking –  is required for space-occupying lesions – eg, tumours, abscess.
  • If surgery cannot be performed – radiotherapy may relieve cord compression caused by malignant disease.
  • Radiation therapy and Chemotherapy – may have a role in treatment if the cauda equina  syndrome is caused by the tumor.
  • Support or brace – A pelvic belt can be used to stabilize a joint that is too loose until the inflammation and pain subside.
  • Joint injections – Numbing injections into the sacroiliac joint are used diagnostically to help identify the cause of the but are also useful in providing immediate pain relief. Typically, an anesthetic is injected along with an anti-inflammatory medication.

Other treatment options

  • Other treatment options –  may be useful in certain patients, depending on the underlying cause of the CES
  • Weakness – Physiotherapy may be helpful if there is no inflammatory component such as that found in arachnoiditis where exercise might exacerbate the condition and cause flare-ups.
  • Sensory Loss – Little conventional treatment exists for sensory loss in cauda Equina syndrome, although in conditions such as Multiple Sclerosis use of vitamin B complex is considered to have potential beneficial effects.
  • Sore Feet – Loss of muscle tone and control over the movement of the foot may lead to foot pain. If foot drop is a notable issue, a brace to hold it in position may help. It is important; however, to attempt to maintain as much muscle tone as possible as well as a range of movement (ROM). Exercises might help.
  • Sexual Dysfunction – Sexual dysfunction is very hard for people to talk about at times. It might be best to pursue advice from specialists. If no physical treatment is feasible for improving function, the person and their sexual partner might pursue counseling which might help to lessen the impact of this disability on not only the person affected, but their partner.
  • Depression – Depression is an understandable reaction to a form of debilitating illness. Antidepressant medication should be reserved for severe depression. Counseling and support are the preferred method of managing depression. Sharing experiences may help people with cauda Equina syndrome to come to terms with the disabilities associated with cauda Equina syndrome.
  • Poor Circulation – Poor circulation is a common issue in cauda Equina syndrome. The person’s feet may be cold and turn white, then red when re-warmed (also known as, ‘Raynaud’s syndrome,) as well as chilblains. Some medications exist that can be taken, yet it is most likely best to use general measures such as avoiding getting cold feet and foot massage with warm oil to help improve the person’s circulation. Avoid extremely hot baths after the feet have been cold because it will most likely cause chilblains.
  • Postoperative care – includes addressing lifestyle issues (eg, obesity), and also physiotherapy and occupational therapy, depending on residual lower limb dysfunction.
  • Prolotherapy – the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body’s healing response – has not been found to be effective by itself, although it may be helpful when added to another therapy.
  • Herbal medicines – as a whole, are poorly supported by evidence.The herbal treatments Devil’s claw and white willow may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant. Capsicum, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.
  • Behavioral therapy – may be useful for chronic pain. There are several types available, including operant conditioning, which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors;
  • Cognitive behavioral therapy – which helps people identify and correct negative thinking and behavior; and respondent conditioning, which can modify an individual’s physiological response to pain. Medical providers may develop an integrated program of behavioral therapies. The evidence is inconclusive as to whether mindfulness-based stress reduction reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain.
  • Tentative evidence supports neuroreflexotherapy (NRT) – in which small pieces of metal are placed just under the skin of the ear and back, for non-specific low back pain

Complications

At first, changes in the way your body functions may be overwhelming. However, your rehabilitation team will help you develop the strategies you need to address the changes caused by the spinal cord injury. Areas often affected include:

  • Bladder control – Your bladder will continue to store urine from your kidneys. However, your brain may not be able to control your bladder as well because the message carrier (the spinal cord) has been injured. The changes in bladder control increase your risk of urinary tract infections. They also may cause kidney infections and kidney or bladder stones. During rehabilitation, you’ll learn new techniques to help empty your bladder.
  • Bowel control –  Although your stomach and intestines work much as they did before your injury, control of your bowel movements is often altered. A high-fiber diet may help regulate your bowels, and you’ll learn techniques to optimize your bowel function during rehabilitation.
  • Skin sensation – Below the neurological level of your injury, you may have lost part of or all skin sensations. Therefore, your skin can’t send a message to your brain when it’s injured by certain things such as prolonged pressure, heat or cold. This can make you more susceptible to pressure sores, but changing positions frequently — with help, if needed — can help prevent these sores. You’ll learn proper skin care during rehabilitation, which can help you avoid these problems.
  • Circulatory control – A spinal cord injury may cause circulatory problems ranging from low blood pressure when you rise (orthostatic hypotension) to swelling of your extremities. These circulation changes also may increase your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus. Another problem with circulatory control is a potentially life-threatening rise in blood pressure (autonomic hyperreflexia). Your rehabilitation team will teach you how to address these problems if they affect you.
  • Respiratory system. Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are affected. These include the diaphragm and the muscles in your chest wall and abdomen.Your neurological level of injury will determine what kind of breathing problems you may have. If you have cervical and thoracic spinal cord injury, you may have an increased risk of pneumonia or other lung problems. Medications and therapy can treat these problems.
  • Muscle tone. Some people with a spinal cord injury experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
  • Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes.A dietitian can help you eat a nutritious diet to sustain an adequate weight. Physical and occupational therapists can help you develop a fitness and exercise program.
  • Sexual health. Sexuality, fertility and sexual function may be affected by spinal cord injury. Men may notice changes in erection and ejaculation; women may notice changes in lubrication.Doctors, urologists and fertility specialists who specialize in spinal cord injury can offer options for sexual functioning and fertility.
  • Pain. Some people experience pain, such as muscle or joint pain, from overuse of particular muscle groups. Nerve pain, also known as neuropathic or central pain, can occur after a spinal cord injury, especially in someone with an incomplete injury.
  • Depression. Coping with all the changes spinal cord injury brings and living with pain causes some people to experience depression. Therapy and medications are available to treat depression associated with living with a spinal cord injury.

References

Incomplete spinal cord injury

Belly Pooch; How to Reduce the Belly Fat Fore Ever

Belly pooch how to reduce the Belly fat forever? Abdominal obesity, also known as central obesity occurs when excessive abdominal fat around the stomach and abdomen has built up to the extent that it is likely to have a negative impact on health. There is a strong correlation between central obesity and cardiovascular disease.  Abdominal obesity is not confined only to the elderly and obese subjects. Abdominal obesity has been linked to Alzheimer’s disease as well as other metabolic and vascular diseases.

Excess belly fat is extremely unhealthy. It’s a risk factor for diseases like metabolic syndrome, type 2 diabetes, heart disease and cancer.

The medical term for unhealthy fat in the belly is “visceral fat,” which refers to fat surrounding the liver and other organs in your abdomen.

Even normal-weight people with excess belly fat have an increased risk of health problems

belly fat .

Sugary Foods and Beverages

Many people take in more sugar every day than they realize.

  • High-sugar foods include cakes and candies, along with so-called “healthier” choices like muffins and frozen yogurt. Soda, flavored coffee drinks and sweet tea are among the most popular sugar-sweetened beverages.
  • Observational studies have shown a link between high sugar intake and excess belly fat. This may be largely due to the high fructose content of added sugars.
  • Both regular sugar and high-fructose corn syrup are high in fructose. Regular sugar has 50% fructose and high-fructose corn syrup has 55% fructose.
  • In a controlled 10-week study, overweight and obese people who consumed 25% of calories as fructose-sweetened beverages on a weight-maintaining diet experienced a decrease in insulin sensitivity and an increase in belly fat.
  • A second study reported a reduction in fat burning and metabolic rate among people who followed a similar high-fructose diet.
  • Although too much sugar in any form may lead to weight gain, sugar-sweetened beverages may be especially problematic. Sodas and other sweet drinks make it easy to consume large doses of sugar in a very short period of time.

What’s more, studies have shown that liquid calories don’t have the same effects on appetite as calories from solid foods. When you drink your calories, it doesn’t make you feel full so you don’t compensate by eating less of other foods instead.

 Alcohol

  • Alcohol can have both healthful and harmful effects. When consumed in moderate amounts, especially as red wine, it may lower your risk of heart attacks and strokes. However, high alcohol intake may lead to inflammation, liver disease, and other health problems. Some studies have shown that alcohol suppresses fat burning and that excess calories from alcohol are partly stored as belly fat — hence the term “beer belly”.
  • Studies have linked high alcohol intake to weight gain around the middle. One study found that men who consumed more than three drinks per day were 80% more likely to have excess belly fat than men who consumed less alcohol.
  • In another study, daily drinkers who consumed less than one drink per day tended to have the least abdominal fat, while those who drank less often but consumed four or more drinks on “drinking days” were most likely to have excess belly fat

Trans Fats

  • Trans fats are the unhealthiest fats on the planet. They’re created by adding hydrogen to unsaturated fats in order to make them more stable. Trans fats are often used to extend the shelf lives of packaged foods, such as muffins, baking mixes, and crackers. Trans fats have been shown to cause inflammation. This can lead to insulin resistance, heart disease, and various other diseases.
  • At the end of a 6-year study, monkeys fed an 8% trans fat diet gained weight and had 33% more abdominal fat than monkeys fed an 8% monounsaturated fat diet, despite both groups receiving just enough calories to maintain their weight.

Inactivity

  • A sedentary lifestyle is one of the biggest risk factors for poor health . Over the past few decades, people have generally become less active. This has likely played a role in the rising rates of obesity, including abdominal obesity.
  • A major survey from 1988-2010 in the US found that there was a significant increase in inactivity, weight and abdominal girth in men and women another observational study compared women who watched more than three hours of TV per day to those who watched less than one hour per day.
  • The group that watched more TV had almost twice the risk of “severe abdominal obesity” compared to the group that watched less TV. One study also suggests that inactivity contributes to the regain of belly fat after losing weight. In this study, researchers reported that people who performed resistance or aerobic exercise for 1 year after losing weight were able to prevent abdominal fat regain, while those who did not exercise had a 25–38% increase in belly fat

Low-Protein Diets

  • Getting adequate dietary protein is one of the most important factors in preventing weight gain. High-protein diets make you feel full and satisfied, increase your metabolic rate and lead to a spontaneous reduction in calorie intake.
  • In contrast, low protein intake may cause you to gain belly fat over the long term. Several large observational studies suggest that people who consume the highest amount of protein are the least likely to have excess belly fat.
  • In addition, animal studies have found that a hormone known as neuropeptide Y (NPY) leads to increased appetite and promotes belly fat gain. Your levels of NPY increase when your protein intake is low.

Menopause

  • Gaining belly fat during menopause is extremely common. At puberty, the hormone estrogen signals the body to begin storing fat on the hips and thighs in preparation for a potential pregnancy. This subcutaneous fat isn’t harmful, although it can be extremely difficult to lose in some cases. Menopause officially occurs one year after a woman has her last menstrual period.
  • Around this time, her estrogen levels drop dramatically, causing fat to be stored in the abdomen, rather than on the hips and thighs.
  • Some women gain more belly fat at this time than others. This may partly be due to genetics, as well as the age at which menopause starts. One study found that women who complete menopause at a younger age tend to gain less abdominal fat.

The Wrong Gut Bacteria

Hundreds of types of bacteria live in your gut, mainly in your colon. Some of these bacteria benefit health, while others can cause problems.

  • The bacteria in your gut are also known as your gut flora or microbiome. Gut health is important for maintaining a healthy immune system and avoiding disease.
  • An imbalance in gut bacteria increases your risk of developing type 2 diabetes, heart disease, cancer, and other diseases. There’s also some research suggesting that having an unhealthy balance of gut bacteria may promote weight gain, including abdominal fat.
  • Researchers have found that obese people tend to have greater numbers of Firmicutes bacteria than people of normal weight. Studies suggest that these types of bacteria may increase the number of calories that are absorbed from food .
  • One animal study found that bacteria-free mice gained significantly more fat when they received fecal transplants of bacteria associated with obesity, compared with mice that received bacteria linked to leanness

Fruit juice is a sugary beverage in disguise.

unsweetened 100% fruit juice contains a lot of sugar.

  • In fact, 8 oz (250 ml) of apple juice and cola each contain 24 grams of sugar. The same amount of grape juice packs a whopping 32 grams of sugar (rx, rx, rx). Although fruit juice provides some vitamins and minerals, the fructose it contains can drive insulin resistance and promote belly fat gain (rx).What’s more, it’s another source of liquid calories that’s easy to consume too much of, yet still fails to satisfy your appetite in the same way as solid food .

Stress and Cortisol

Cortisol is a hormone that’s essential for survival.

  • It’s produced by the adrenal glands and is known as a “stress hormone” because it helps your body to mount a stress response. Unfortunately, it can lead to weight gain when produced in excess, especially in the abdominal region. In many people, stress drives overeating. But instead of the excess calories being stored as fat all over the body, cortisol promotes fat storage in the belly.

Low-Fiber Diets

Fiber is incredibly important for good health and controlling your weight. Some types of fiber can help you feel full, stabilize hunger hormones and reduce calorie absorption from food.

  • In an observational study of 1,114 men and women, soluble fiber intake was associated with reduced abdominal fat. For each 10-gram increase in soluble fiber, there was a 3.7% decrease in belly fat accumulation.
  • Diets high in refined carbs and low in fiber appear to have the opposite effect on appetite and weight gain, including increases in belly fat.
  • One large study found that high-fiber whole grains were associated with reduced abdominal fat, while refined grains were linked to increased abdominal fat.

Genetics

  • Genes play a major role in obesity risk. Similarly, it appears that the tendency to store fat in the abdomen is partly influenced by genetics. This includes the gene for the receptor that regulates cortisol and the gene that codes for the leptin receptor, which regulates calorie intake and weight.
  • In 2014, researchers identified three new genes associated with increased waist-to-hip ratio and abdominal obesity, including two that were found only in women.

Not Enough Sleep

  • Getting enough sleep is crucial for your health. Many studies have also linked inadequate sleep with weight gain, which may include abdominal fat. One large study followed over 68,000 women for 16 years. Those who slept 5 hours or less per night were 32% more likely to gain 32 lbs (15 kg) than those who slept at least 7 hours.
  • Sleep disorders may also lead to weight gain. One of the most common disorders, sleep apnea, is a condition in which breathing stops repeatedly during the night due to soft tissue in the throat blocking the airway.

In one study, researchers found that obese men with sleep apnea had more abdominal fat than obese men without the disorder

Take Home Message

  • Many different factors can make you gain excess belly fat. There are a few you can’t do much about, like your genes and hormone changes at menopause. But there are also many factors you can control.
  • Making healthy choices about what to eat and what to avoid, how much you exercise and how you manage stress can all help you lose belly fat. So let’s go for a solution…

HOW TO RID YOURSELF OF BELLY POOCH FOREVER

belly fat
If you’re like many other people, losing the fat around your midsection is the biggest problem area in your weight loss journey. You’ve watched the numbers on the scale fall but haven’t seen a corresponding loss in belly fat.
  • Fat spot reduction is impossible because you can’t tell your body where to burn fat.  Numerous tummy crunches simply do not encourage your body to burn fat from your tummy.  However, crunches do help tone and build your abdominal muscles.  That means when your body eventually gets around to burning your tummy fat, you will reveal a perfectly toned mid-section as a result of all your abdominal work.
  • Your clothes are fragrant and look cool on you. But how is your belly? Well, here is a problem you might have. Belly fat has become a scary story for men and women worldwide. In addition to this, an unhealthy, fat belly shape can reduce a person’s confidence.
  • That’s why every man and women want to lose belly fat fast and naturally. If this is your problem, you have to prove that you have enormous willpower to solve this problem. The effort is the base of one’s success. Here are some tips and home remedies to lose belly fat fast and regain your confidence.
How many times have you lost the weight around your midsection just to see it latch right back on once you’ve relaxed a little bit? To get rid of that belly fat once and for all, it might be time to check out some of these options below.

Check your fiber

  • Women should consume 25-30 grams of fiber every day. Fiber will help to relieve you of any extra air in your digestive system that causes bloating. Be careful though, too much fiber has also been known to cause a bit of pooch. Check your diet and be sure you’re getting a balanced amount.

Work that core

  • Crunches make for a great core workout, but they don’t hit all of your abdominal muscles.Get ready to sweat as Real Mom Model Tina leads you through an ab-strengthening circuit that begins with 30 reps of each exercise, then 20 reps and a final 10. This workout boosts your metabolism, improves your endurance and strengthens your core. Grab a mat and get started!

Snack better

Snacks are not your enemy, but the unhealthy ones are. Instead of cookies, chips or crackers, grab a small handful of nuts or an apple.

Change your diet 

  • If you want to lose weight, you have to watch your calories. It’s easier said than done but the basics of weight loss require you to burn more calories than you consume. Cut out unhealthy snacks and start eating cleaner. You’ll see your body change when your eating habits do.

Change up your cardio 

  • Instead of going at a constant pace, try to incorporate intervals. This is a proven way to burn through fat. Next time you’re on the treadmill, try speeding up in short bursts! You’ll be challenging yourself and burning that stubborn fat.

Organic Apple cider Vinegar

  • Mix 2 tablespoons of organic apple cider vinegar and one tablespoon of honey and 8 ounces of pure water.Take this 2- 3 times a day to jump start the fat reduction program.

Drink Water 

  • Diet drinks that promise a slim body may work, just like what fresh fruit juices and other healthy drinks do. Do not consume any other drink than water, which contains calories. The trick here is to steer clear from any unwanted calories. Water is what you will only drink to lose tummy fat. Besides, water has the ability to get rid of toxins that contribute to unwanted weight. Water speeds up your metabolism as well. If you cannot take the “plain” taste of water, you add some drops of lemon or mint leaves to it.

Cloves 

 
  • Eat raw garlic Chew two to three cloves of garlic every morning, and drink a glass of lemon water after that. This treatment will double up your weight loss process and make your blood circulation smooth in your body.

Aerobic Exercise

 
  • While any kind of exercise burns fat, high-intensity aerobic exercise burns visceral fat the best. Resistance training and low-impact exercise have been shown to mostly target subcutaneous fat. So, if you want to burn that stubborn belly fat, kick it into high gear and go for high-intensity aerobics, at least 30 minutes 3-5 times a week.

Broom Stick 

 
  • Do the 6 minute love handle workout in the video above 1-to-4 times per day 1-to-3 days per week or.You could simply do 2-to-6 sets of 8-to-20 reps on each side 1-to-3 days per week but once the broomstick gets too easy.

Lemon Water

 
  • Drink lemon water. As I said before, after garlic, squeeze one lemon in a glass of warm water and add a pinch of salt. This will speed up your metabolism and clean toxins out of the body. Sassy water is a great combination to cut the fat around the stomach.

Detox Diet 

 
  • Detox diet contains only fruits, vegetables and detox water. Mainly it includes only fruit and vegetable juices. It is meant to flush out all the toxins and helps in reducing like hell within a week. If detox does not suit you then leave it immediately. The first day you may feel hungry and tired but your body will get used to it second and third day.

 Green tea

 
  • Drink four cups of green tea a day. Green tea is a great fat burner. It is a natural phenol antioxidant, which speeds up the metabolism. With its regular consumption, you can lose up to 13 pounds (6 kg) within eight weeks.

Cardio Exercise

  • There are so many exercise choices for burning fat and you need to choose a cardio routine that will help you shed weight and tone up all over.  Follow my 10 minute cardio body blast or pick something simple and low-cost to start like walking, jogging or cycling.  Try to go at a consistent pace that has you working at 60-80% of your maximum heart rate and aim to do 30 minutes a day of fat-burning cardio.  Soon you’ll be toned all over and you’ll have whittled your waist beautifully.

Rice

 
  • Stay off from white rice Replace white rice with various wheat products. Include brown rice, brown bread, whole grains, oats and quinoa in your diet.

QUICK TIPS TO LOSE WEIGHT

Related image

Find out the successful tips to lose weight below. It is obvious that eating less and moving more is the key secret to lose weight. And these tips will boost your weight loss efforts.

  • Eat Slow – When eating, the body takes almost 15-20 minutes to feel fullness. One can save up to 70 calories if they eat slow. If you make the habit of eating slowly then it will help you to lose weight about two pounds in a month.
  • Consume Water-filled foods – You can eat water-filled foods such as salads, soups, watermelon because it will help you to feel fuller in just fewer calories. And as per the researcher, if you start your meal with a broth-based soup, it will help you to avoid from eating more and thereby boost your weight loss effort.
  • Make sure to have breakfast – As per the research study it has shown that people who do regular breakfast are more successful at losing weight. So, you should start eating your breakfast with full of fiber and protein because it will keep you fuller all morning.
  • Move away from the screen – While having lunch or dinner just move away from the screen. If you do so, no matter what you are eating will help you from over-eating and will keep you feel fuller.
  • Increase your fiber intake – If you increase the daily intake of fiber then it will help you to avoid weight gain and may promote weight loss. As per the research study people who have increased the daily intake of fiber has normally lost their weight than who decreased the fiber intake has gained the weight.

References

Transverse Myelitis – Causes, Symptoms, Diagnosis, Treatment

Transverse myelitis (TM) is a neurological disorder caused by inflammation of the spinal cord. Attacks of inflammation can damage or destroy myelin, the fatty insulating substance that covers nerve cell fibers and send impulses from the brain to the nervous system in the whole body. The spinal cord also carries sensory information back to the brain. The term myelitis refers to inflammation of the spinal cord; transverse refers to the pattern of changes in sensation—there is often a band-like sensation across the trunk of the body, with sensory changes below. This causes scars that interrupt communication between the nerves in the spinal cord and the rest of the body.

Transverse myelitis (TM) is a pathogenetically heterogeneous focal inflammatory disorder of the spinal cord characterized by acute or subacute development of motor weakness, sensory impairment, and autonomic dysfunction. [rx] MRI of the spinal cord reveals a focal hyperintense lesion and cerebrospinal fluid usually shows pleocytosis. The causes of TM are heterogeneous, but partial TM (asymmetric, short cord lesions) is associated with multiple sclerosis, whereas longitudinally extensive lesions are associated with neuromyelitis optica spectrum disorders. [rx][rx] [rx]

Transverse myelitis can affect people of any age, gender, or race. It does not appear to be genetic or run in families. The disorder typically occurs between ages 10 and 19 years and 30 and 39 years.

Transverse Myelitis

Types of Transverse Myelitis

  • Ascending Myelitis
  • Brown-Sequard Syndrome
  • Concussion Myelitis
  • Foix-Alajouanine Myelitis
  • Funicular Myelitis
  • Subacute Necrotizing Myelitis
  • Systemic Myelitis

Pathophysiology

This demyelination arises idiopathically following infections or due to multiple sclerosis. One major theory posits that immune-mediated inflammation is present as the result of exposure to a viral antigen. The diarrhea-causing bacteria Campylobacter jejuni is also a reported cause of transverse myelitis. The lesions are inflammatory and involve the spinal cord typically on both sides. With acute transverse myelitis, the onset is sudden and progresses rapidly in hours and days. The lesions can be present anywhere in the spinal cord, though they are usually restricted to only a small portion.

Causes of Transverse Myelitis 

http://rxharun.com/Transverse Myelitis 

The exact cause of transverse myelitis and extensive damage to nerve fibers of the spinal cord is unknown in many cases.  Cases in which a cause cannot be identified are called idiopathic.  However, looking for a cause is important, as some will change treatment decisions.

A number of conditions appear to cause transverse myelitis, including:

  • Immune system disorders.  These disorders appear to play an important role in causing damage to the spinal cord.  Such disorders are:
    • an aquaporin-4 autoantibody associated neuromyelitis optica
    • multiple sclerosis
    • the post-infectious or post-vaccine autoimmune phenomenon, in which the body’s immune system mistakenly attacks the body’s own tissue while responding to the infection or, less commonly, a vaccine
    • an abnormal immune response to underlying cancer that damages the nervous system; or
    • other antibody-mediated conditions that are still being discovered.
  • Viral infections –  It is often difficult to know whether a direct viral infection or a post-infectious response to the infection causes transverse myelitis. Associated viruses include herpes viruses such as varicella-zoster (the virus that causes chickenpox and shingles), herpes simplex, cytomegalovirus, and Epstein-Barr; flaviviruses such as West Nile and Zika; influenza, echovirus, hepatitis B, mumps, pertussis, tetanus, diphtheria, measles, and rubella.
  • Bacterial infections  – Such as syphilis, tuberculosis, actinomyces, and Lyme disease.  Bacterial skin infections, middle-ear infections, campylobacter jejuni gastroenteritis, and mycoplasma bacterial pneumonia have also been associated with the condition.
  • Fungal infections – In the spinal cord, including Aspergillus, Blastomyces, Coccidioides, and Cryptococcus.
  • Parasites – Including Toxoplasmosis, Cysticercosis, Schistosomiasis, and Angtiostrongyloides.
  • Other inflammatory disorders – That can affect the spinal cord, such as sarcoidosis, systemic lupus erythematosus, Sjogren’s syndrome, mixed connective tissue disease, scleroderma, and Bechet’s syndrome.
  • Vascular disorders – Such as arteriovenous malformation, dural arterial-venous fistula, intraspinal cavernous malformations, or disk embolism.
  • Multiple sclerosis  – Is a disorder in which the immune system destroys myelin surrounding nerves in your spinal cord and brain. Transverse myelitis can be the first sign of multiple sclerosis or represent a relapse. Transverse myelitis as a sign of multiple sclerosis usually causes symptoms on only one side of your body.
  • Neuromyelitis Optica (Devic’s disease)  – Is a condition that causes inflammation and myelin loss around the spinal cord and the nerve in your eye that transmits information to your brain. Transverse myelitis associated with neuromyelitis optica usually affects both sides of your body.

Symptoms of Transverse Myelitis 

There are disturbances in sensory nerves and motor nerves and dysfunction of the autonomic nervous system at the level of the lesion or below. Therefore, the signs and symptoms depend on the area of the spine involved

Transverse Myelitis 

  • Cervical – If the upper cervical cord is involved, all four limbs may be involved and there is a risk of respiratory paralysis (cervical nerve segments C3, 4, 5 innervate the abdominal diaphragm). Lesions of the lower cervical (C5–T1) region will cause a combination of upper and lower motor neuron signs in the upper limbs and exclusively upper motor neuron signs in the lower limbs. Cervical lesions account for about 20% of cases.
  • Thoracic – A lesion of the thoracic spinal cord (T1–12) will produce upper motor neuron signs in the lower limbs, presenting as spastic diplegia. This is the most common location of the lesion, and therefore most individuals will have weakness of the lower limbs.
  • Lumbar – A lesion of the lower part of the spinal cord (L1–S5) often produces a combination of upper and lower motor neuron signs in the lower limbs. Lumbar lesions account for about 10% of cases.

Transverse Myelitis 

Other early symptoms can include:

  • Pain –  Transverse myelitis pain may begin suddenly in your lower back. Sharp pain may shoot down your legs or arms or around your chest or abdomen. Pain symptoms vary based on the part of your spinal cord that’s affected.
  • Abnormal sensations – Some people with transverse myelitis report sensations of numbness, tingling, coldness, or burning. Some are especially sensitive to the light touch of clothing or to extreme heat or cold. You may feel as if something is tightly wrapping the skin of your chest, abdomen, or legs.
  • Weakness in your arms or legs –  Some people notice that they’re stumbling or dragging one foot, or heaviness in the legs. Others may develop severe weakness or even total paralysis.
  • Sensitivity to touch (allodynia) — experienced by as many as 80 percent of people; a sensitivity in which clothing or a light touch with a finger causes significant discomfort or pain.
  • Sensory alterations. Transverse myelitis can cause paresthesias(abnormal sensations such as burning, tickling, pricking, numbness, coldness, or tingling) in the legs and sensory loss. Abnormal sensations in the torso and genital region are common.
  • Bowel and bladder dysfunction – Common symptoms include an increased frequency or urge to use the toilet, incontinence, and constipation. Many individuals also report experiencing muscle spasms, a general feeling of discomfort, headache, fever, and loss of appetite, while some people experience respiratory problems. Other symptoms may include sexual dysfunction and depression and anxiety caused by lifestyle changes, stress, and chronic pain.
  • Weakness – in the arms or legs (paraparesis)
  • Sensory symptoms (paresthesias) such as numbness, tingling, burning, tickling, or prickling in the legs, feet, or toes.
  • Heightened sensitivity to changes in temperature or to extreme heat or cold.
    Muscle weakness
  • Muscle and/or joint pain
  • Breathing or swallowing difficulties
  • Increased sensitivity to cold temperatures
  • Difficulty in sleeping
  • A decline in the ability to perform basic daily activities.
  • Fatigue.

Diagnosis of Transverse Myelitis

In 2002 the Transverse Myelitis Consortium Working Group proposed the following diagnostic criteria for idiopathic acute transverse myelitis:

Inclusion criteria

  • Motor, sensory or autonomic dysfunction attributable to spinal cord
  • Signs and symptoms on both sides of the body (not necessarily symmetrical)
  • Clearly defined the sensory level
  • Signs of inflammation (pleocytosis of the cerebrospinal fluid, or elevated immunoglobulin G, or evidence of inflammation on gadolinium-enhanced (MRI) Magnetic resonance imaging)
  • The peak of this condition can occur anytime between 4 hours to 21 days after onset.Transverse Myelitis 

Exclusion criteria

  • Irradiation of the spine (e.g., radiotherapy) in the last 10 years
  • Evidence of thrombosis of the anterior spinal artery
  • Evidence of extra-axial compression on neuroimaging
  • Evidence of arteriovenous malformation (abnormal flow voids on surface of spine)
  • Evidence of connective tissue disease, e.g. sarcoidosis, Behçet’s disease, Sjögren’s syndrome, systemic lupus erythematosus or mixed connective tissue disease
  • Evidence of optic neuritis (diagnostic of neuromyelitis optica
  • Evidence of infection (syphilis, Lyme disease, Human immunodeficiency virus, Human T-lymphotropic virus 1, mycoplasma, Herpes simplex virus, Varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, Human herpesvirus 6 or enteroviruses)
  • Evidence of multiple sclerosis (abnormalities detected on MRI and presence of oligoclonal antibodies in cerebrospinal fluid(CSF))
  • Blood tests may be performed to rule out various disorders such as HIV infection, vitamin B12 deficiency, and many others.  Blood is tested for the presence of autoantibodies (anti- aquaporin-4, anti-myelin oligodendrocyte) and a host of antibodies associated with cancer (paraneoplastic antibodies) that may be found in people with transverse myelitis.
  • Lumbar puncture (also called a spinal tap) uses a needle to remove a small sample of the cerebrospinal fluid that surrounds the brain and spinal cord.  In some people with transverse myelitis, the cerebrospinal fluid contains more protein than usual and an increased number of white blood cells (leukocytes) that help the body fight infections.
  • Computerized tomography (CT) scan – uses powerful magnets or radio waves to make a detailed image, while a CT scan puts several X-rays together for a more complete picture than one X-ray alone.
  • Magnetic resonance imaging(MRI) – produces a cross-sectional view or three-dimensional image of tissues, including the brain and spinal cord. A spinal MRI will almost always confirm the presence of a lesion within the spinal cord, whereas a brain MRI may provide clues to other underlying causes, especially MS. In some instances, computed tomography (CT) may be used to detect inflammation.

Transverse Myelitis 

Treatment of Transverse Myelitis

Treatments are designed to address infections that may cause the disorder, reduce spinal cord inflammation, and manage and alleviate symptoms.

Initial treatments and management of the complications of transverse myelitis

  • Intravenous corticosteroid drugs – may decrease swelling and inflammation in the spine and reduce immune system activity.  Such drugs may include methylprednisolone or dexamethasone (usually administered for 3 to 7 days and sometimes followed by a tapering off period).  These medications may also be given to reduce subsequent attacks of transverse myelitis in individuals with underlying disorders.
  • Plasma exchange therapy – (plasmapheresis) may be used for people who don’t respond well to intravenous steroids.  Plasmapheresis is a procedure that reduces immune system activity by removing plasma (the fluid in which blood cells and antibodies are suspended) and replacing it with special fluids, thus removing the antibodies and other proteins thought to be causing the inflammatory reaction.
  • Intravenous immunoglobulin (IVIG) – is a treatment thought to reset the immune system.  IVIG is a highly concentrated injection of antibodies pooled from many healthy donors that bind to the antibodies that may cause the disorder and remove them from circulation.
  • Pain medicines – that can lessen muscle pain include acetaminophen, ibuprofen, and naproxen.  Nerve pain may be treated with certain antidepressant drugs (such as duloxetine), muscle relaxants (such as baclofen, tizanidine, or cyclobenzaprine), and anticonvulsant drugs (such as gabapentin or pregabalin).
  • Antiviral medications – may help those individuals who have a viral infection of the spinal cord.
  • Medications can treat other symptoms and complications – including incontinence, painful muscle contractions called tonic spasms, stiffness, sexual dysfunction, and depression.
  • Maintaining strong bones – People with transverse myelitis are at an increased risk of developing osteoporosis because of limited activity. Talk to your doctor about calcium and vitamin D supplements to improve bone health. Weight-bearing exercises, if possible, will also strengthen bones.
  • Preventing bowel problems – If you have bowel problems caused by transverse myelitis, eat a fiber-rich diet and drink plenty of fluids to help prevent constipation.
  • Antiviral medications – may help individuals who have a viral infection of the spinal cord.
  • Medications can treat other symptoms and complications – including incontinence, painful muscle contractions called tonic spasms, stiffness, sexual dysfunction, and depression.

Following initial therapy, it is a critical part to keep the person’s body functioning while hoping for either complete or partial spontaneous recovery of the nervous system.

Management of Neuromyelitis Optica

Medication Use Typical dose Evidence
  • High dose IV methylprednisolone
Acute 1 gm IV daily for 5 days with or without a taper Observational studies
  • Plasma exchange
Acute as a rescue therapy 5 exchanges (each exchange 250 ml) over 5-10 days Randomized trials in TM patients
  • Rituximab
Maintenance 1 gm (or 375 mg/m2) IV every 1-2 weeks for 2-4 weeks then redoes based on CD19 count (typically every 6-8 month) for ≤ 2 years Several open label and retrospective clinical trials
  • Azathioprine
Maintenance 2 mg/kg PO divided BID (typically 100 mg BID) for ≤2 years Observational studies
  • Mycophenolate
Maintenance 1-3 gm PO daily divided BID or TID for ≤2 years Retrospective trial
  • Methotrexate
Maintenance 5-15 mg PO weekly for ≤2 years Open label trial
  • Mitoxantrone
Maintenance 12 mg/mevery 3 months (maximum dose 140 mg/m2) Open-label trial
  • Cyclophosphamide
Maintenance 0.5-1.5 mg/m2 (typically 1 gm) IV every month until absolute lymphocyte count<1000/mm(typically 6 cycles) or immunoablative dose of 200 mg/kg divided over 4 days Open-label trial
  • IVIG
Maintenance 2 gm/kg induction followed by 0.4-0.5 gm/kg every month Case series

Prevention of future transverse myelitis 

  • Most transverse myelitis only occurs once (called monophasic).  In some cases, chronic (long-term) treatment with medications to modify the immune system response is needed.  Examples of underlying disorders that may require long-term treatment include multiple sclerosis and neuromyelitis optica.
  • Treatment of MS with immunomodulatory or immunosuppressant medications may be considered when it is the cause of myelitis.   These medications include alemtuzumab, dimethyl fumarate, fingolimod, glatiramer acetate, interferon-beta, natalizumab, and teriflunomide, among others.

Immunosuppressants

  • Treatments are used for neuromyelitis optica spectrum disorder and recurrent episodes of transverse myelitis that are not caused by multiple sclerosis. They are aimed at preventing future myelitis attacks (or attacks at other sites) and include steroid-sparing drugs such as mycophenolate mofetil, azathioprine, and rituximab.

Rehabilitative and long-term therapy

Many forms of long-term rehabilitative therapy are available for people who have disabilities resulting from transverse myelitis.  Strength and functioning may improve with rehabilitative services, even years after the initial episode.  Rehabilitative therapy teaches people strategies for carrying out activities in new ways in order to overcome, circumvent, or compensate for permanent disabilities.  Although rehabilitation cannot reverse the physical damage resulting from transverse myelitis, it can help people, even those with severe paralysis, become as functionally independent as possible and attain the best possible quality of life.

Common neurological deficits resulting from transverse myelitis include severe weakness, spasticity, or paralysis; incontinence, and chronic pain.  In some cases these may be permanent.  Such deficits can substantially interfere with a person’s ability to carry out everyday activities such as bathing, dressing, and performing household tasks.   Individuals with lasting neurological defects from transverse myelitis typically consult with a range of rehabilitation specialists, who may include physiatrists (physicians specializing in physical medicine and rehabilitation), physical therapists, occupational therapists, vocational therapists, and mental health care professionals.

  • Physical therapy – Can help retain muscle strength and flexibility, improve coordination, reduce spasticity, regain greater control over bladder and bowel function, and increase joint movement.  It also can help to reduce the likelihood of pressure sores developing in immobilized areas.  Individuals are also taught to use assistive devices such as wheelchairs, canes, or braces as effectively as possible.
  • Occupational therapy – Teaches people new ways to maintain or rebuild their independence by participating in meaningful, self-directed, everyday tasks such as bathing and dressing.  Therapists teach people how to function at the highest level possible, by developing coping strategies, suggesting changes in their homes to improve safety (such as installing grab bars in bathrooms), and changing obstacles in their environment that interfere with normal activity.
  • Vocational therapy –  Involves offering instructions to help people develop and promote work skills, identify potential employers, and assist in job searches.  Vocational therapists act as mediators between employees and employers to secure reasonable workplace accommodations.
  • Psychotherapy – For people living with permanent includes strategies and tools to deal with stress and a wide range of emotions and behaviors.

Supportive therapy and acute rehabilitation

Supportive therapy for individual symptoms such as respiratory distress, pain, and urinary retention may be added to the treatment regimen as required.

  • Respiratory failure – in a minority of patients with cervical TM, the lesion extends into the medulla and may cause neurogenic respiratory failure. Close observation of respiratory parameters, including measurement of maximal respiratory pressures and forced vital capacity, and involvement of a skilled critical care team are recommended in cases of ascending cervical myelitis.
  • Neuropathic pain – may be acute or chronic. Acute pain can be treated with narcotic analgesics, gabapentin, or carbamazepine. Chronic pain often responds to anticonvulsants or tricyclic antidepressant drugs.
  • Acute urinary retention – may be managed by bladder catheterization. Residual neurogenic bladder symptoms may include urge incontinence, retention, or a mixed disorder, each of which requires specific treatment.
  • DVT prevention – immobilized patients are at increased risk. Extrapolation of data from general medical and orthopedic surgery patients indicates that subcutaneous heparin or enoxaparin plus use of lower extremity compression stockings or devices reduces the risk of DVT.

Acute rehabilitation consists of passive and active therapy to maintain range of motion of limbs; reduce spasticity, spasms, and risk of contractures; and reduce the risk of decubitus ulceration.

Herbal/Ayurvedic/Home Treatment

  • Omega-three fatty acids help reduce inflammation from any cause and very effective in a dose of 5-7 grams daily in acute attacks.
  • Turmeric is very effective in the treatment of spinal cord inflammation use 1-2 grams daily in milk. In allopathic medications, steroids and IVIg are both effective and there is a huge role of antibiotics and antiviral.
  • If the organism is unknown then use a Tens unit, Hulda Clark zapper, or silver colloid. Hydrogen peroxide is an alternative experimentally used in the treatment. Finally are old cases of untreated transverse myelitis please consider stem cell transplant. At cidpusa.org we have had great success with doxycycline in the treatment of transverse myelitis.
  • A patient has treated with ganciclovir and cytomegalovirus (CMV) hyperimmune globulin. He gradually improved and recovered completely within 4 weeks. This case suggests that ganciclovir and CMV hyperimmune globulin appear to be effective for the treatment of EBV-induced transverse myelitis in immunocompromised patients following BMT. (Bone Marrow Transplant)

Homeopathic Remedies

  • Ledum Pal– Pain along the entire course of the nerve and pain increased by movement and better by rest. Better by placing the limb in ice-cold water.
  • Agaricus– Weakness and trembling with stiffness all over. Itching of toes and feet feels frozen. Cramps in soles of the feet and spasmodic contraction of the arms.
  • Tarantula Hisp– Sensation of insects crawling under the skin, extreme restless of the limbs with a desire to move constantly, which partially relieves all the complaints.

What research is being done?

The mission of the National Institute of Neurological Disorders and Stroke (NINDS) is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease. NINDS is a component of the National Institutes of Health, the leading supporter of biomedical research in the world.

NINDS researchers are working to better understand how the immune system destroys or attacks the nerve-insulating substance called myelin in autoimmune diseases or disorders. Other work focuses on strategies to repair demyelinated spinal cords, including approaches using cell transplantation. This research may lead to a greater understanding of the mechanisms responsible for damaging myelin and may ultimately provide a means to prevent and treat transverse myelitis.

Glial cell studies. Glia, or neuroglia, are non-neuronal cells (they do not provide electrical impulses) in the nervous system that form myelin and provide support and protection for neurons. Oligodendrocyte progenitor cells (OPCs) are stem cells that generate myelin-producing oligodendrocytes, a type of glial cell. NINDS-funded scientists are studying cellular mechanisms that control the generation and maturation of OPCs to allow remyelination, which could be an effective therapy for transverse myelitis and spinal cord injury. Other NINDS-funded investigators are focusing on mechanisms and interventions designed to increase oligodendrocyte proliferation and remyelination after spinal cord injury.

Astrocytes are another type of glial cell. The aquaporin-4 IgG antibody binds to astrocytes, which has led to an increased interest in its role in transverse myelitis of neuromyelitis optica spectrum disorder (NMOSD). The antibody appears to cause myelitis in NMOSD by activating other components of the immune system, resulting in injury to the spinal cord. Many studies are trying to better understand the role of astrocytes in autoimmune diseases.

Genetic studies. NINDS-funded scientists hope to develop a better understanding of the molecular control of central nervous system myelination and remyelination by studying theBrg1(Brahma-related) gene that appears to be involved in oligodendrocyte myelination. The long-term objective of this research is to develop drugs that modulate the activity ofBrg1and other genes to promote myelination and remyelination.

Animal models. NINDS funds research using animal models of spinal cord injury aimed at replacing or regenerating spinal cord nerve cells. The ultimate goals of these studies are to develop interventions for regeneration or remyelination of spared nerve fibers in humans and to restore function to paralyzed individuals.

Neuroimaging with MRI. Research funded by NINDS aims to develop and implement new MRI techniques to quantitatively assess the relationship between spinal cord pathology and neurological dysfunction in MS. This new approach may assess changes in lesions and myelin in MS and possibly transverse myelitis.Other NIH-funded researchers plan to develop MRI methodologies to non-invasively detect and characterize networks to identify the extent of injury to the spinal cord and to monitor the progression of recovery after injury. These techniques may aid in earlier detection of transverse myelitis and other neurological disorders such as MS.

Brain-machine interfaces and prosthetic devices. Scientists are developing brain-machine interfaces and neural prostheses to help people with spinal cord damage regain functions by bypassing the injury site. These sophisticated electrical and mechanical devices connect with the nervous system to supplement or replace lost motor and sensory function.

References

Transverse Myelitis

Face Skin Care; Best way to Tightening Your Skin of Face

Face skin care is the range of practices that support skin integrity, enhance its appearance and relieve skin conditions. They can include nutrition, avoidance of excessive sun exposure and appropriate use of emollients. Practices that enhance appearance include the use of cosmetics, botulinum, exfoliation, fillers, laser resurfacing, microdermabrasion, peels, retinol therapy. Skin care is a routine daily procedure in many settings, such as skin that is either too dry or too moist, and prevention of dermatitis and prevention of skin injuries.

Skin care is a part of the treatment of wound healing, radiation therapy and some medications.

Time and tide wait for none and so do the aging signs. Due to aging, the elastin and collagen structure of the skin loses elasticity and the skin loses some of its self-moisturizing components making it appeared loose and saggy. Plus, age can make the facial muscles weak, which also contributes to saggy skin.rxharun.com/Skin-Structure-and-Function

In addition to aging, skin can lose its elasticity because of excessive exposure to harmful sun rays, excessive smoking, regular intake of alcoholic beverages, obesity, pregnancy, rapid weight loss, a poor diet, use of wrong skin care products,  dehydration and use of harsh chemicals on the skin.

Along with sagging skin, you may also notice an increase in wrinkles and fine lines, especially on your face. Skin may also look paler and more translucent, and it may become more sensitive.

Face Skin Care /Tightening Health Tips

Facial Massage

If you do facial massage daily before bedtime, your skin becomes tightening. This is because facial massage is effective in boosting the blood circulation to your face. Moreover, massage in upward and circular motions can help to slow down the aging process and prevent the early appearance of aging signs such as wrinkles and fine lines.

Therefore, when you apply a suitable moisturizer to your skin, you should not ignore massaging your face and your neck.

Many people neglect their neck because they do not know that the neck skin is vulnerable to fine lines and wrinkles due to stress and pressure. Do you want to know more effective ways for natural skin tightening? Continue reading this article to know more.

rxharun.com/Skin-Structure-and-Function

Regular Exercise

Loosening or saggy skin is caused by rapid weight loss. In these cases, it is recommended building a regular exercise program or taking part in moderate physical activities to tone the muscle and boost the growth of connective tissue matrix.

In order to improve the loosening or saggy skin, headstands and inversion exercises are recommended. This is because these exercises are effective in reducing the influence of gravity and toning the saggy skin. Moreover, exercise can increase the blood circulation that helps to boost the rejuvenation of skin cells.

Proper Diet

Unhealthy and improper diet can lead to not only unwanted weight change but also saggy skin. People who skip meals, eat fast foods, processed foods and eat late in the evening are more prone to get the saggy skin.

To make sure that your body is well-shaped and your skin is toned and tight, you should follow a rich nutrient high-quality diet that is loaded with omega 3 fatty acids, proteins, essential amino acids in order to rejuvenate and boost the growth of new skin cells and the development of connective tissues. Moreover, it is important for you to add more fresh fruits and vegetables into your daily diet. Colorful fruits and green vegetables have a great source of vitamins, minerals, and antioxidants that are essential nutrients for the bright, young, and healthy skin

Saltwater Bath

Saltwater bath is also included in a list of effective ways for natural skin tightening. In order to tone and tighten skin, you just need to add two teaspoons of sea salt in the bath filled with warm water. Relax in the bath for 20 minutes. The saltwater bath can help to tighten skin because it can eliminate impurities and toxins for your skin. Impurities and toxins may lead to the saggy skin by interfering with the production of collagen. It is recommended taking a saltwater bath on every two days.

Avoid Exposure To UV Rays

We all know that UV rays present in the sunlight are harmful to skin. Overexposure to sunlight and UV rays can lead to sunburn, skin damages and even skin cancer. Most people know that. However, not many people acknowledge that sunlight and UV rays may worsen the sagging of skin by damaging your superficial skin layers and affecting the collagen of skin. Therefore, you should limit sun rays exposure with the help of sunscreen and creams. Intense sun can remove the moisture as well as the natural oils from your skin and reduce collagen that plays the important role in keeping the skin’s elasticity. Therefore, these are logical reasons for you to put sunscreen onto your skin.

After you wear sunscreen and makeup during all day long, it is important for you to remove the makeup and sunscreen before bedtime with oil cleanser or makeup removal.

Oil Massage

Massage your saggy skin with natural oils like olive oil. You should repeat this method daily to tighten skin and retain skin firm and smooth. Olive oil is one of the wonderful natural oils that are loaded with vitamin A and vitamin E. Moreover, olive oil contains antioxidant and anti-aging properties. Applying olive oil to the skin can make skin moisturized and glowing.

Do you want to use olive oil to get rid of sagging skin? You should read the following instruction to know more:

  • Put a sufficient amount of olive oil in a microwave for a few minutes to make this oil warm
  • Apply this oil to your saggy skin areas such as your face, neck, arm or belly
  • Use your fingertips to massage your skin gently in circulation motions for about 10 minutes

Massage method with olive oil should be repeated once daily before bedtime to get a satisfactory result.

Besides olive oil, you can use avocado, coconut, almond oil, grape seed, or jojoba oil to massage your legs, arms, neck, and face.

Quit Smoking

For natural skin tightening, you should quit smoking. This is because smoking influence in the development and growth of new skin cells. Furthermore, smoking can affect the manufacture of collagen. People who have the habit of smoking is more likely to suffer from a variety of metabolic, neoplastic and other medical disorders. Therefore, it is important for you to quit smoking for natural skin tightening and good physical health. Some cosmetic productions may worsen the saggy skin. Therefore, you should avoid using cosmetic products when you have saggy skin.

Strawberries

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Because strawberries contain astringent properties; it is one of natural skin tightening remedies. This fruit has a great source of vitamin C, an excellent antioxidant, which slow down the aging process and boost the manufacture of collagen. Moreover, strawberries are loaded with fiber that makes skin firmer and smoother. The alpha hydroxyl acids present in this fruit are effective in improving skin complexion and slowing down the appearance of aging signs.

Are you interested in using strawberries to tighten skin? You should do this.

  • Mash 2 or 3 strawberries
  • Mix mashed strawberries with 2 tablespoons of yogurt
  • Apply this paste to your saggy skin
  • Let this paste sit on your skin for about 10 minutes
  • Rinse it off with lukewarm water

This natural solution for skin tightening should be repeated once a week until you can see a significant improvement.

Furthermore, you should add strawberries into your diet in order to get the best and fastest result

 Exfoliating Skin

Looking for the natural skin tightening solutions, you should not ignore exfoliation. Most people know that exfoliating skin is the important step in skin care routine to freshen skin, get rid of dead skin cells, boost the blood circulation, boost the formation of new skin cells and supply vital nutrients and oxygen to the skin. However, how to use exfoliating method for natural skin tightening?

Dry brushing, an excellent method, is not expensive. A body brush that is made with the natural fibers is found abundant in many local beauty supplies and local drugstores.

Hydrate Skin With Oil

Another remedy for natural skin tightening is hydrating your skin with oil. After taking a shower, you just need to spread a coat of oil over your skin to trap the moisture and improve the skin’s elasticity.

Some natural oils that contain hydrating effects include almond oil, baby oil, and castor oil.

You just need to choose one of these natural oils you want and add some drops into your bath. Repeat this way once daily to make your skin infused with natural oil. Relaxing in the bath also help you to feel more comfortable and relieved.

 Drink 8 Glasses Of Water

rxharun.com/a glass of water

One of the amazing tips for natural skin tightening is drinking a plenty of water to make sure that your skin is hydrated well. It is recommended drinking 6 to 8 glasses of water during the day for the most satisfactory result.

Moreover, in order to not only keep your skin hydrated but also provide your body with a plenty of essential nutrients, coconut water, and herbal teas are excellent choices besides water.

Coffee, as well as alcohol, should be avoided because they can dehydrate your body and your skin overtime.

Honey And Peach

The combination of honey and peach becomes one of effective home remedies for natural skin tightening I would like to introduce to you in this article. Honey contains moisturizing and antibacterial properties. The honey application can give you a glowing and beautiful skin.  Peach is a healthy fruit because of rich nutrient content. Many people like eating peach due to its delicious taste and flavor. Peach is considered as a natural exfoliant because it has a great source of alpha hydroxyl acids. Therefore, peach is not only eaten but also used topically. Topical application of peach is effective in smooth, tighten and reduce aging signs overtime.

Do you want to use honey and peach for natural skin tightening?

Get this:

  • 1 medium peach
  • 1 tablespoon of yogurt
  • 1 tablespoon of honey

Do this:

  • Boil the peach in water to make it soften
  • Grind the boiled peach in a bowl
  • Add yogurt and honey in this bowl
  • Stir it well to create a smooth paste
  • Spread this smooth paste over your saggy skin such as your face, neck, stomach and buttocks
  • Allow it sit on your skin for about 15 to 20 minutes
  • Rinse it off with lukewarm water
  • Splash your skin with cold water

If you use the honey and peach mask for facial skin, you should apply your favorite moisturizer to make skin glowing and gorgeous. In order to get a satisfactory result, the honey and peach mash should be applied once or twice a week for one or two months.

Weight Training Program

The sagged skin can be improved by weight training. Weight training is effective in toning the muscles of your body. If you want to find an effective weight training, cardio workouts are recommended for reducing weight, toning the muscles, and tightening skin. And then you just need to add the weight training into a workout for skin tightening. Make sure that you practice weight training regularly to strengthen the muscles of your body and lighten skin.

 Do Yoga

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Yoga also helps to strengthen the muscles and tighten skin. After the weight loss, the skin may become saggy and loosening. Yoga reduces these issues by toning skin and boosting the blood circulation. It is a reason why yoga is considered as an exercise for not only health but also beauty.

Therefore, it is a great idea if you can take some yoga classes each week. However, if you do not have enough time and financial budget, you can do yoga a home by watching and following many online videos shared on the internet.

 Practice Calisthenics

Calisthenics is exercised practiced in the gym classes. Calisthenics are beneficial in toning the facial and body skin. Some calisthenics exercises that can help to lighten skin include pull-ups, push-ups, jumping jacks & lunges, sit-ups & squats.

Avoid Using Harsh Soaps

Using harsh soaps can worsen the sagged skin. This is because a lot of harsh soap products contain sodium laurel sulfate and other related chemicals that may cause skin damages and make skin dry. Therefore, if you want to improve your skin condition, you should avoid using harsh soaps or industrial-strength cleansers.

For good reasons, you should opt for natural skin lightening products to wash your face. Moreover, cleansers containing oil as a key ingredient are the best choice for natural skin tightening.

How To Tighten Face Skin with Papaya And Rice Flour Face Pack

You will prepare:

  • 1 papaya
  • 1/4 cup of rice flour
  • 2 tablespoons of honey

Practice:

  • Firstly, take 1 ripped papaya and mash it finely. To it add the rice flour. Now mix them well and create a paste.
  • Finally add the honey to it and now mix all of them together.
  • After this, apply this paste on to the face. After 20 minutes, wash it with lukewarm water.

How To Tighten Face Skin with Fuller’s Earth & Milk Face Pack

You will prepare:

Milk with cream

  • Fuller’s earth

Practic

  • Take milk containing cream and pour 2 tablespoons of fuller’s earth in this.
  • Blend this solution well and later apply on your face.
  • Finally, wash off by using lukewarm water.

How To Tighten Face Skin with Apple Cider Vinegar

You will need:

  • 1/4 cup of apple cider vinegar
  • 1/2 cup of water

Practice:

  • First of all mix the apple cider vinegar with water well and later anoint your face by using the solution.
  • Let it dry naturally and finally wash it off.
  • Alternatively, after you bathe wash you can wash your face by using vinegar mixed in water. This will make the face feel tighter and look softer.

How To Tighten Face Skin with Lemon And Olive Oil Face Pack

You will prepare:

  • 3-4 tablespoons of olive oil
  • 2-3 tablespoons of lemon juice

Practice:

  • Take the olive oil at first and mix 2-3 tbsp lemon juice to it.
  • Mix them well and apply this mixture on the face.
  • Leave it for half an hour and lastly, wash by using the warm water.

Egg White, Fuller Earth And Honey Face Pack

You will prepare:

  • 2 tablespoons of fuller’s earth
  • 1 tablespoon of honey
  • Egg white

Practice:

  • In a glass bowl, take the fuller’s earth and add honey. Later mix them well and add the egg white.
  • Mix again and apply this pack on your face and keep for 20 minutes.
  • Finally, wash off with the help of lukewarm water. If you have dry skin, then use glycerin and flour instead of honey and fuller’s earth.

How To Tighten Face Skin with Besan And Curd Face Pack

Both besan and curd help to make the skin revitalized, firm and refreshed when applied regularly. Besan helps in getting rid of tan, dead skin and zits. It also brightens the skin complexion and increases the tone. Plus, besan is a good remedy to cure your skin from dullness and aging. This pack will tighten your skin and improves the blood circulation as well.

Practice:

  • First of all, take one teaspoonful each of curd and gram flour.
  • Mix them well and apply as one thick layer on your face.
  • As it gets dried completely wash it off.

How To Tighten Face Skin with Blueberry And Honey Face Mask

You will prepare:

  • 2 tablespoons of honey
  • ½ cup of blueberries

Practice:

  • Firstly, blend the blueberries in a blender to achieve a smooth paste.
  • Then, anoint your face by using the unprocessed honey thoroughly.
  • After that, apply this blueberry paste over that honey smoothened face.
  • Wait for 30 minutes and rinse with the help of lukewarm water. You will notice the difference on the face.

Egg White And Gram Flour

This combination is also a wonderful remedy to tighten the face skin. How to tighten face skin with this combination? Follow these steps below:

Practice:

  • Mix some gram flour with egg white at first. Mix it properly and then apply on the face.
  • Let it get dry and finally wash with water.
  • Follow this pack thrice in a week. This pack can be used on your arms, neck, and breasts as well.

How To Tighten Face Skin Naturally & Fast with Grapes

Practice

  • You just need to take a little grapes juice and later massage on your face and neck.
  • Leave it for 30 minutes and then wash it off by using water.

How To Tighten Face Skin With Rose Water

  • You should apply a little of rose water over your face and neck before going to bed.
  • And, keep it overnight, you will wash your skin in the next morning.
  • You will be surprised at the result that it brings about.

Alternatively, you can do:

  • Firstly, you combine the equal amount of witch hazel and lemon juice with a small amount of almond oil.
  • And then, you add the mixture into a cup of rose water.
  • After that, you can apply this mixture over your face & neck,
  • Finally, you have to leave it for 20 minutes before rinsing it off. Do this mixture a few times a week.

Egg White Mask

Practice:

  • Firstly, you beat the egg & separate the egg yolk from the white.
  • And then, you apply the egg white on your face & wait until it dries.
  • Finally, you wash your face with warm water.

Avocado And Cucumber Mask

  • 1 egg white
  • 2 tablespoons of powdered milk
  • A half of cup avocado (peeled and chopped)
  • A half of cup cucumber (peeled and chopped)

Practice:

  • Firstly, you only mix the above ingredients till they are smooth.
  • And then you have to chill the mixture for one hour.
  • After that it has sufficiently refrigerated, you apply it directly to your face and neck.
  • You allow the mixture to rest for 30 minutes before washing it off with warm water.
  • Finally, you can finish with a pool of cool water.

How To Tighten Face Skin – Flour And Egg White Mask

Ingredients:

  • 1 Egg white
  • Glycerin for dry skin
  • Flour or fuller’s earth
  • Honey

Prepare:

  • Firstly, you beat one egg & separate the yolk from white.
  • And you mix honey, flour, glycerin to it and you can apply on your face skin.
  • Finally, you wait until it dries and rinse off with warm water.

In addition, you can use Multani mitti or Fuller’s Earth. If your skin is oily, you should avoid adding glycerin. Multani mitti or Fuller’s earth helps you improve your skin tone, eliminate pimples, and fight against blemishes. It removes excess oil from your skin & promotes blood circulation in the face. You should use flour regularly but Multani mitti occasionally when you buy it from the market. You must remember that Multani mitti is only used for oily skin & not for sensitive or dry skin.

How To Tighten Face Skin Using Cinnamon

This is one of the good home remedies on how to tighten face skin you can safely practice without hesitation. It has been used in traditional medicines for centuries in Asian cultures-Chinese as well as Indian. Cinnamon plays a vital role in keeping healthy skin. Plus, it helps treat various skin related infections and diseases. It helps grow up the manufacture of collagen that is necessary to firm, and tighten skin. Cinnamon also helps promote the complexion due to its anti-fungal and anti-bacterial qualities. Moreover, it can soften dry and rough skin thanks to  its rich anti-oxidant agents.

  • You mix 1 tbsp. cinnamon powder with sugar and salt.
  • And then, you scrub it softly over your face and neck for 5 to 10 minutes.
  • After that, you wash your face with lukewarm water.

Rice Flour And Cabbage Mask

Generally, rice flour acts as the dead skin cells remover and skin pores cleaner. Particularly, women around the world used rice flour for beauty for thousands of years. The Geisha in Feudal Japan used it to keep their skin soft and smooth. It also helps ward off hyper-pigmentation, aging and UV exposure. Cabbage, on the other hand, contains the minerals such as phosphorus, potassium, and vitamins such as A, B etc, which all help to reduce and prevent the loose facial skin.

Ingredients:

  • Few drops of olive oil or almond oil
  • 2 tablespoons of rice flour
  • 2-3 cabbage leaves

Practice:

  • Firstly, you grind and create a mixture of cabbage leaves.
  • And you mix it finely with olive oil or almond oil and rice flour.
  • Finally, you apply it on your skin face and keep it dry. After that, you wash it well with tepid water.

 How To Tighten Face Skin With Honey And Cabbage Mask

Ingredients:

  • Olive oil or almond oil for dry skin
  • Cabbage leaves
  • Honey
  • Yogurt

Practice:

  • Firstly, you take 2-3 cabbage leaves & make a mixture of them.
  • And you combine this mixture finely with honey and yogurt in a container. If you have a dry skin, you can add olive oil or almond oil to the paste.
  • Then you apply this mixture and keep it for 15-20 minutes.
  • Finally, you rinse clearly with tepid water.

To see the best result, you should practice regularly. In addition, there are a lot of other healthy tips on how to tighten face skin naturally and fast at home presented in the next part of this writing, so if you want to discover more about them, continue reading!

Honey

Honey has anti aging and antioxidant properties and natural hydrating property that are one of the helpful treatments on how to tighten face skin. You should choose two ways:

  • Way 1: You mix two teaspoons of honey with a few drops of lemon juice & olive oil. And then you apply it over your face and neck, keep it dry & finally wash it off with lukewarm water. You should practice this mixture once or twice daily to see the best results.
  • Way 2: You can also mix a half tablespoon of honey with sour cream. And then mix in a half small spoon of turmeric powder. You use the mixture on your face skin for 15 minutes. Finally, you wash it off with tepid water and then splash with cold water. You should practice this face mask once per week.

 How To Tighten Face Skin With Sandalwood

 

Practice

You mix rose water with sandalwood powder in an equal ratio of 1:1. Then you can apply evenly over your face. When it dries, you rinse your face with cool water. This mixture will also help in eliminating oil from the skin pores and diet.

Lemon And Egg Whit

Practice:

  • To temporarily close your face skin pores as well as have a radiant look, you can use egg white mask when you want to see quickly results.
  • You separate the yolk from egg white and then you add a few drops of lemon juice.
  • You whisk thoroughly and gently till a frothy consistency is reached.
  • You apply the paste with a brush and keep it dry. Finally, you wash your face clearly with warm water.

How To Tighten Face Skin Using Milk And Honey

Practice:

  • Firstly, you mix 1 tablespoon of honey with 5 tablespoons of milk & vitamin E oil (few drops).
  • And then you apply the paste on your face about twice per week.
  • Finally, you wash your face after 15 minutes for a bright and toned skin.

How To Tighten Face Skin With Banana

  • And then you apply this smooth mixture on your face and neck.
  • You wait for about half an hour. Finally, you wash your skin with tepid water. You make sure that you practice this face mask twice a week & you will notice the difference it brings about.

 Cucumber

To tighten your face skin, you can apply cucumber. It is also one of the greatest natural face skin toners, and has a rejuvenating and refreshing effect on skin. Cucumber acts as a key element for one long-lasting beauty regime. It’s extremely useful for firming up your skin and tightening it as well. Moreover, cucumber reduces and reverses signs of ageing such as fine lines, dull skin and wrinkles thanks to its potassium and manganese. You can choose three following treatments on how to tighten face skin with cucumber:

  • You mash half a cucumber and then you squeeze it by a strainer to take its juice. You apply this juice over your face skin and keep it on till it dries. Finally, you wash it off with fresh water. You should follow this way every day.
  • You can also mix 1 tablespoon of mashed cucumber and plain yogurt. You apply this mixture on your face and keep it on for about 10 to 15 minutes. Then you wash it off with tepid water. You should repeat twice or three times per week.
  • You can also create a face mask with one egg white, two tablespoons of cucumber juice and vitamin E oil (three to five drops). You apply this mask over your face and neck, keep it on about 15 minutes, & then rinse it off with fresh water. You should use this mask once per week.

How To Tighten Face Skin Using Lemon

Lemon has vitamin C that helps promote collagen production. This also helps regenerate elasticity to your skin. Furthermore, lemon has astringent properties, which help tighten your skin and lower wrinkles as well as other symptoms of early aging.

  • You squeeze some fresh lemon juice & rub it lightly on your neck and face skin. You keep it on about 5 to 10 minutes & then you wash your face with cool water. You should do this twice or three times per day and you should carry out with the good quality moisturizer.
  • Alternatively, you can also mix the juice of one-half a lemon into a glass of cold water. You splash this mixture over your freshly washed face. You keep the lemon water to dry on your face. You should follow this way once or twice daily to see the best results.

How To Tighten Face Skin with Aloe Vera

One of the best treatments on how to tighten face skin is aloe vera. The malic acid of aloe vera gel can help improve the elasticity of the face skin & get rid of your skin sagging. In addition, it is a natural moisturizer for the skin. It also helps to reduce sagging skin on neck and face. It will tighten and firm your loose skin, decreasing the size of the skin pores.

  • You take the gel from one aloe vera leaf and apply it on your neck and face. You let it on about 15 to 20 minutes & then you rinse it off with tepid water. You should follow this way several times per week.
  • Another way is to mix one spoon of aloe vera gel with one teaspoon of mayonnaise and honey. You apply this paste on your neck and face. You keep it on your face for 15 minutes. Finally, you wash your skin off with tepid water and then splash with cold water. You should do this way once per week to see the results.

 Facial Massage

Regular Exercise

Many women show the loosening skin when they lose weight rapidly. In all those cases, moderate physical activity can help in improving your skin tightening by boosting muscle build-up & growing of connective tissue matrix.

Proper Diet

You consume a high-quality diet containing proteins, omega- fatty acids, and essential amino-acids to rejuvenate or remodel of your skin. You should increase your intake of vegetables and fresh fruits to supply minerals, vitamins, and antioxidants for younger, bright, and healthy looking skin.

 How To Tighten Face Skin With Saltwater Bath

On every two days, you can add two teaspoons of sea salt in the bathing water. This will help in tightening skin by eliminating toxins and impurities from your skin that can interfere with the restructuring of collagen.

Avoid Sun Rays

Ideally, you should limit your exposure to the sun rays by using of creams and sunscreen. This may help you stop the damage to your superficial skin layers. Furthermore, because intense sun can rob moisture and the natural oils from your skin, boosting collagen destruction, so now you have more reasons to use sunscreen onto your skin. You should also remove makeups before going to bed.

 Oil Massage

You should massage your neck and face skin with natural oils such as olive oil to help in tightening the face skin to retain its smooth and firm. Olive oil has antioxidants such as vitamins E and A, which provide anti-aging benefits. In addition, it will also help retain your skin well moisturized.

  • Firstly, you warm slightly some virgin olive oil in your microwave.
  • And you use this oil on your face skin.
  • Then you massage lightly with your fingertips in circle motions for 10 minutes.
  • You should practice this way once daily before bedtime.

You can also use coconut, avocado, grape seed, almond oil, or jojoba to massage your arms, legs, face and neck.

 No Smoking – The Simplest Way How To Tighten Face Skin

One of the irritants, which affects the growth & development of skin cells as well as interferes with the manufacture of collagen, is smoking. Quitting smoking as soon as possible not only promotes your physical health, but also prevents you from the variety of neoplastic, metabolic, and other medical disorders. Furthermore, you can also get back your youthful face skin without any cosmetic production.

How To Tighten Face Skin with Strawberries
  • You mash about 2 to 3 ripe strawberries
  • And then you mix them with about 2 teaspoons of yogurt and 2 teaspoons of
  • Next, you apply this paste onto your face &
  • Then, you leave it on there for about 5 to 10 minutes
  • Finally, you rinse your face and neck off with the lukewarm water.
  • You should follow this natural solution once daily until you see the improvement.
Exfoliate Your Skin

 

  • In the morning you brush the skin before taking a shower (pay attention: both the brush and your skin should be dry)
  • You can use long strokes in order to brush your arms & legs. You work your way from the feet to the thighs, and then from the hands to the shoulders. You always brush toward the hands in the direction the blood circulates.
  • You should focus on areas where the skin is loose.
  • Finally, you do not forget your buttocks and stomach
Use Oil To Hydrate Your Skin

Another easy tip on how to tighten face skin is using oil to keep the skin hydrated. After showering, you can apply a coat of oil in order to help trap the moisture into your skin, and then the skin’s elasticity will be improved. Some natural oils you can use to keep the skin hydrated are baby oil, almond oil, and castor oil. Try adding some drops of one among these oils to your bath. Following this way daily will make the skin get infused with that oil when you relax.

 Drink Plenty Of Water

One among other healthy and effective tips on how to tighten face skin is drinking plenty of water to keep the skin hydrated. So, make sure you are getting the plenty of water during the day. You can drink 6 to 8 glasses of water for best results. In addition, drinking coconut water as well as herbal teas may also help you in staying hydrated and providing the body with a lot of essential nutrients. However, you need to avoid drinking an excessive amount of coffee and alcohol, because these drinks can dehydrate the body over time.

 How To Tighten Face Skin – Honey And Peach Mask
  • 1 tablespoon of yogurt
  • 1 tablespoon of. honey
  • 1 medium amount of peach

Oatmeal Face Mask For Skin Tightening

Oatmeal-Face-Mask-For-Skin-Tightening

 
You Will Need
  • 1 tablespoon oats
  • 1 tablespoon besan (gram flour)
  • 1 teaspoon honey
  • Rose water
What You Have To Do

1. Grind the oats to get a grainy powder.
2. Add gram flour, honey, and enough rose water to get a paste.
3. Apply this pack on your face and neck and leave it on for 10 minutes.
4. Rinse with water.

Clay Mask For Skin Tightening

You Will Need
  • 2 tablespoons bentonite or Kaolin clay
  • 1 teaspoon powdered milk
  • Water or rose water
What You Have To Do
  1. Mix all the ingredients to get a thick paste.
  2. Apply it evenly with your fingers or a face mask brush all over the face and neck.
  3. Let the mask dry for 10-15 minutes. Rinse your face.

Castor Oil Face Pack For Skin Tightening

 
You Will Need
  • 1-2 tablespoons castor oil
  • 1 teaspoon lemon juice OR a few drops of lavender oil
What You Have To Do
  1. Add either lemon juice or lavender oil to the castor oil and mix well.
  2. Massage this mixture in upward circular motions on the face and neck. Keep massaging for a few minutes.
  3. Leave it on overnight.
  4. Rinse with lukewarm water first, followed by cool water.
 rxharun.com/Skin-tightening pic-of -face

All the ingredients mentioned in the remedies above are usually found easily at home. These natural ingredients have many advantages to offer. So, start taking care of your skin right now! The various constituents of these ingredients deal with different issues such as dryness, sagging, and wrinkles. Once these issues are eliminated, your skin will definitely be firmer and smoother.

 

 

Constipation; Causes, Symptoms, Diagnosis, Treatment

Constipation refers to bowel movements that are infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

Constipation is a health problem that influences almost 20% of the world’s population[]. It is a bothersome disorder which negatively affects the quality of life and increases the risk of colon cancer[]. There are a wide-range of treatment methods. Lifestyle modification, such as increased fluid intake or exercise, is usually recommended as first-line treatment, but data on the effectiveness of these measures are limited[]. Laxatives are most commonly used for the treatment of constipation, but frequent use of these drugs may lead to some adverse effects[,], alternative treatment measure is, therefore, needed. Soluble fiber absorbs water to become a gelatinous, viscous substance and is fermented by bacteria in the digestive tract. Insoluble fiber has a bulking action[]. Dietary fiber is the product of healthful compounds and has demonstrated some beneficial effect. The increase of dietary fiber intake has been recommended to treat constipation in children and adults[]. In a large-population case-control study, Rome found that dietary fiber intake was independently negatively correlated with chronic constipation, despite the age range and the age at onset of constipation[].

Constipation

Epidemiology of 

Constipation is the most common chronic gastrointestinal disorder in adults. Depending on the definition employed, it occurs in 2% to 20% of the population. It is more common in women, the elderly and children. Specifically constipation with no known cause affects females more often affected than males. The reasons it occurs more frequently in the elderly is felt to be due to an increasing number of health problems as humans age and decreased physical activity.

  • 12% of the population worldwide reports having constipation.
  • Chronic constipation accounts for 3% of all visits annually to pediatric outpatient clinics.
  • Constipation-related health care costs total $6.9 billion in the US annually.
  • More than four million Americans have frequent constipation, accounting for 2.5 million physician visits a year.
  • Around $725 million is spent on laxative products each year in America.

Constipation

 

Causes of Constipation

People’s regular toilet habits can be affected by many things, including.

  • Busy lifestyles
  • Changes of routine, including holidays, starting school
  • Not eating enough fibre
  • Not drinking enough water or fluids
  • Not taking enough exercise, being sedentary
  • Ignoring natural urges to go to the toilet, sometimes due to not being near a toilet you are comfortable using
  • Emotional and psychological problems
  • Health conditions, including Parkinson’s disease, an under-active thyroid gland and depression
  • Age and circumstances
  • Bottle-feeding for babies
  • Some medications, including narcotic-type pain killers such as codeine, iron supplements and some drugs used to control blood pressure.

Causing Secondary Constipation

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Congenital malformations
Structural causes or mechanical obstruction
  •  Colon cancer
  • Benign stricture
  • Rectocele, enterocele, rectal prolapse
  •  Megacolon
  • Fissures
Metabolic
  • Hypothyroidism
  • Hypercalcemia
  • Hypokalaemia
  • Uraemia
  • Coeliac disease
Myopathies
  • Scleroderma
  • Amyloidosis
Neuropathies
  • Spinal injury
  • Myelomeningocele
  • Multiple sclerosis
  • Diabetic neuropathy
  • Cerebrovascular disease
  • Parkinson’s disease
Complications from surgery or irradiation therapy
Depression
Cognitive impairment
Immobility

 

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Constipation

Why Does It Happen?

Some causes of constipation include

  • Antacid medicines containing calcium or aluminum
  • Changes in your usual diet or activities
  • Colon cancer
  • Eating a lot of dairy products
  • Eating disorders
  • Irritable bowel syndrome
  • Neurological conditions such as Parkinson’s disease or multiple sclerosis
  • Not being active
  • Not enough water or fiber in your diet
  • Overuse of laxatives
  • Pregnancy
  • Problems with the nerves and muscles in the digestive system
  • Resisting the urge to have a bowel movement, which some people do because of hemorrhoids
  • Some medications (especially strong pain drugs such as narcotics, antidepressants, or iron pills)
  • Stress
  • An underactive thyroid (called hypothyroidism)

Drugs that Cause constipation prescription drugs that cause constipation include pain relievers like opiates etc.

The drug that causes constipation especially among the elderly include

  • Opioid pain relievers like Morphine, Codeine, etc.
  • Anticholinergic agents like Atropine, Trihexyphenidyl
  • Antispasmodics like dicyclomine
  • Tricyclic antidepressants like amitriptyline
  • Calcium channel blockers used in arrhythmias and high blood pressure such as verapamil
  • Anti-Parkinsonian drugs – Parkinson’s disease itself may cause constipation and the drugs used for this condition including Levodopa cause constipation as well
  • Sympathomimetics like ephedrine and terbutaline. Terbutaline is commonly used on bronchial asthma
  • Antipsychotics like clozapine, thioridazine, chlorpromazine used for psychiatric disorders
  • Diuretics for heart failure like furosemide
  • High blood pressure-lowering agents like methyldopa, clonidine, propranolol, etc.
  • Antihistamines like diphenhydramine
  • Antacids especially calcium and aluminum-containing
  • Calcium supplements
  • Iron supplements
  • Antidiarrheal agents (loperamide, attapulgite)
  • Anticonvulsants e.g. phenytoin, clonazepam
  • Pain relievers or NSAIDs (Nonsteroidal anti-inflammatory drugs) like ibuprofen, aspirin, etc.
  • Miscellaneous compounds including Octreotide, polystyrene resins, cholestyramine (for lowering high blood cholesterol) and oral contraceptives

Symptoms of constipation

Constipation

Constipation symptoms include

  • Hard, compacted poor that is difficult or painful to pass
  • Straining during bowel movements
  • No bowel movements after 3 days
  • Stomach aches that are relieved by bowel movements
  • Bloody stools due to hard poo, piles (hemorrhoids) and anal fissures
  • Leaks of wet, almost diarrhea-like poo between regular bowel movements
  • Complications of constipation
  • Complications of constipation include:
  • Dry, hard poo collecting in the rectum, called fecal impaction.
  • Leakage of liquid stools called fecal incontinence.
  • Straining on the toilet and constipation leading to piles.

Diagnosis of Constipation

In addition to a general physical exam and a digital rectal exam, doctors use the following tests and procedures to diagnose chronic constipation and try to find the cause:

  • Blood tests – Your doctor will look for a systemic condition such as low thyroid (hypothyroidism).
  • Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy) – In this procedure, your doctor inserts a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon.
  • Examination of the rectum and entire colon (colonoscopy) – This diagnostic procedure allows your doctor to examine the entire colon with a flexible, camera-equipped tube.
  • Evaluation of anal sphincter muscle function (anorectal manometry). In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels.
  • Evaluation of anal sphincter muscle speed (balloon expulsion test) – Often used along with anorectal manometry, this test measures the amount of time it takes for you to push out a balloon that has been filled with water and placed in your rectum.
  • Evaluation of how well food moves through the colon (colonic transit study ) – In this procedure, you may swallow a capsule that contains either a radiopaque marker or a wireless recording device. The progress of the capsule through your colon will be recorded over several days and be visible on X-rays.
  • In some cases, you may eat radiocarbon-activated food and a special camera will record its progress (scintigraphy). Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon.
  • An X-ray of the rectum during defecation (defecography). During this procedure, your doctor inserts a soft paste made of barium into your rectum. You then pass the barium paste as you would stool. The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.
  • MRI defecography. During this procedure, as in barium defecography, a doctor will insert contrast gel into your rectum. You then pass the gel. The MRI scanner can visualize and assess the function of the defecation muscles. This test also can diagnose problems that can cause constipation, such as rectocele or rectal .
  • transit study examination – where you take a short course of special capsules that show up on X-rays; one or more X-rays are taken later on to see how long it takes for the capsules to pass through your digestive system
  • anorectal manometry – where a small device with a balloon at one end is inserted into your rectum and attached to a machine that measures pressure readings from the balloon as you squeeze, relax and push your rectum muscles; this gives an idea of how well the muscles and nerves in and around your rectum are working.

Constipation

Treatment of Constipation

Most cases of constipation are easy to treat at home with diet and exercise. Some cases require doctor recommendations, prescription medicine, or a medical procedure.

At-home treatment includes

Diet – Eating a healthy diet with fiber and drinking plenty of fluids (water is the most helpful) can usually clear up constipation.

  • High fiber foods include beans, dried fruits, fresh fruits and vegetables, whole-grain foods (choose brown rice or whole wheat bread instead of white), flaxseed meal, and powdered products containing psyllium. For example, 3 cups of popped popcorn have a little more than 3 grams of fiber. One cup of oatmeal has 4 grams of fiber. Adding fiber to each meal and snack will help you reach your goal for the day. Fiber supplements are helpful. Processed foods, such as desserts and sugary drinks, only make constipation worse.
  • Men over the age of 50 should get at least 38 grams of fiber per day.
  • Women over 50 should get 25 grams per day.
  • Children ages 1 to 3 should get 19 grams of fiber per day.
  • Children between 4 and 8 years old should get 25 grams per day.
  • Girls between 9 and 18 should get 26 grams of fiber each day. Boys of the same age range should get between 31 and 38 grams of fiber per day.
  • Bowel training – Teach your children to go to the bathroom when they have to. Holding it can lead to constipation. This also may be necessary for your elderly parents, if you are caring for them.
  • Laxatives – This is over-the-counter medicine that helps you have a bowel movement. Laxatives should only be used in rare instances. Do not use them on a regular basis. If you have to use a laxative, bulk-forming laxatives are best. These work naturally to add bulk and water to your stools so they can pass easily. Bulk-forming laxatives can cause some bloating (when your stomach feels full) and gas.

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Anti- Ulcerant

Antiulcer Drugs
Brand Name
(Generic Name)
Possible Common Side Effects Include:
Axid (nitzatidine) Diarrhea, headache, nausea and vomiting, sore
throat
Carafate (sucralfate) Constipation, insomnia, hives, upset stomach,
vomiting
Cytotec (misoprostol) Cramps, diarrhea, nausea, gas, headache,
menstrual disorders (including heavy bleeding
and severe cramping)
Pepcid (famotidine) Constipation or diarrhea, dizziness, fatigue,
fever
Prilosec (omeprazole) Nausea and vomiting, headache, diarrhea,
abdominal pain
Tagamet (cimetidine) Headache, breast development in men, depres-
sion and disorientation
Zantac (ranitidine
hydrochloride)
Headache, constipation or diarrhea, joint pain

Treatment can be include

Type Generic and brand names Forms How fast? Safe to use long-term? Available as a generic?
bulk-forming psyllium (Metamucil, Konsyl), calcium polycarbophil (FiberCon), methylcellulose fiber (Citrucel) powder, granules, liquid, tablet, packet, wafer a few days yes yes
lubricant mineral oil (Fleet Mineral Oil Enema) enema, oral liquid 6 to 8 hours no yes
osmotic magnesium hydroxide (Phillips Milk of Magnesia), magnesium citrate, polyethylene glycol (Miralax), sodium phosphate (Fleet Saline Enema), glycerin (Fleet Glycerin Suppository) enema, suppository, oral liquid 30 minutes or less yes yes
stimulant bisacodyl (Dulcolax), senna/sennoside (Senokot) enema, suppository, oral liquid or capsule 6 to 10 hours no yes
stool softener docusate (Colace, DulcoEase, Surfak)

 

Enema, suppository, oral tablet, capsule, or liquid 1 to 3 days yes yes

 

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Here are prescription drugs used for the treatment of chronic constipation

  • Linaclotide (Linzess) – This drug is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bowel movements occur more often. It is not approved for use in those aged 17 years and younger. The most common side effect of Linzess is diarrhea. Linaclotide is an agonist of guanylate cyclase-C receptors, which stimulates intestinal fluid secretion and transit. In early studies, it has been found to increase bowel movement frequency and loosen stool consistency. A recently published dose range-finding study and results from two Phase III trials in 1272 patients with chronic constipation, show that linaclotide significantly improved bowel function (measured as ≥3 complete SBMs (SCBM) per week, with an increase of ≥1 from baseline for ≥9 of 12 weeks) in up to approximately 20% of patients. The median time to first SBM was 21.9 h (150 μg).Furthermore, abdominal symptoms, global measures of constipation and quality of life were also significantly improved  and there was no evidence of rebound constipation upon treatment cessation. The most common AEs were GI-related, of which diarrhea had the highest incidence.Linaclotide is currently not licensed for use in the EU.
  • Other 5-HT4 agonists – Other enterokinetic agents in development include the 5-HT4 receptor agonists TD-5108 (Phase II), and ATI-7505 (Phase II). A number of other prokinetic 5-HT4 receptor agonists have been developed for GI disorders, which are of considerable therapeutic interest but are in the early stages of development.
  • Lactulose (Cephula, Chronulac, Constulose, Duphalac, Enulose) – Lactulose, a prescription laxative with a variety of brand names, draw water into the bowel to soften and loosen the stool. Side effects include gas, diarrhea, upset stomach, and stomach cramps.
  • Lubiprostone (Amitiza) – Amitiza is approved by the FDA for the treatment of chronic constipation from an unknown cause (not constipation due to another condition or treatment). Amitiza softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food. Some reported side effects of Amitiza include a headache, nausea, diarrhea, abdominal pain, and vomiting.
  • Plecanatide (Trulance)  – Taken once a day, this tablet is a guanylate cyclase-C agonist. It helps stimulate intestinal fluid secretions that help your stool transit through the bowel. It was developed specifically for those suffering from Chronic Idiopathic Constipation. Side effects include diarrhea. It’s not recommended for use in patients younger than 6 years of age because of the dangers of severe dehydration.
  • Polyethylene glycol (Miralax, Glycolax ). This drug is an osmotic laxative and causes water to remain in the stool, which results in softer stools. For those patients who do not tolerate dietary fiber supplements, this medication may be recommended.
  • Prucalopride – Prucalopride is highly selective for the 5-HT4 receptor, unlike cisapride, displaying at least 150-fold selectivity for its therapeutic target receptor. Early studies demonstrated that it decreased colonic transit time in normal and constipated subjects. Three large randomized Phase III controlled trials with a total of 1977 patients (1750 female and 227 male) with severe chronic constipation (defined as ≤2 SCBM/week for a minimum of 6 months with either very hard or hard stools, sensation of incomplete evacuation or straining during defecation for at least 25% of the time) confirmed that, averaged over 12 weeks, bowel function (measured as an increase of ≥1 SBM/week) was significantly improved in up to 69% of patients receiving the recommended dose of 2 mg prucalopride, with a median time of 2.5 h to first SBM.
  • Colchicine – is an alkaloid substance, which is used as an anti-inflammatory agent. It can increase the frequency of bowel movements, where it may be prescribed as a remedy for the treatment of chronic constipation. Alvimopan and methylnaltrexone have been recently suggested as new agents for the treatment of constipation caused by the opioid.
  • Alvimopan – has been recommended for postoperative ileus after surgeries by the Food and Drug Administration (FDA), while FDA indicated that methylnaltrexone could be applied for patients suffering from opioid-induced constipation. However, trials of alvimopan in the confirmed use of methylnaltrexone in in opioid-induced constipation represent seriously dangerous cardiovascular causes with opposite results in terms of efficacy.[] In addition, the efficacy of commercially available synbiotic elements has been previously evaluated for the treatment of functional constipation in males.[]
  • Mineral oil – Do not use this without your doctor’s recommendation. Your doctor may recommend using it if you recently had surgery and should not strain for a bowel movement. Do not use it regularly. It causes your body to lose important vitamins A, D, E and K.
  • Enema – This is a liquid medicine. It is inserted into your anus to help with constipation. It is often used after a surgery or before some medical procedures.
  • Prescription medicine – Your doctor will prescribe a medicine based on the reason for your constipation.
  • Medical procedures – This is done to help remove stool from the intestine.
  • Surgery – This is rare. It might involve removing a damaged intestine for serious reasons.
  • Opioid antagonists – Three mu-opioid antagonists (naloxone, methylnaltrexone, and alvimopan) are currently under evaluation for the treatment of opiate-induced constipation  and postoperative ileus. Although endogenous opioids may play a role in modulating GI function, early reports suggested that opioid antagonists are not effective in idiopathic constipation.

Biofeedback Therapy

Previous studies reported that biofeedback therapy could be effectively efficient by using neuromuscular training, visual, and verbal feedback. It has priority over other therapies such as laxative and sham training.[]

Biofeedback session implicates placing a probe into the anus to give feedback of muscle tension using a computer screen. Biofeedback therapy is an efficient and multidisciplinary approach without the adverse effects of therapy.[] It has been observed that more than 70% of patients with gastrointestinal disorders get rid of symptoms by treating biofeedback therapy.[]

Laxatives

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Bulk laxatives
  • Dietary fiber, psyllium, polycarbophil, methylcellulose, carboxymethylcellulose
Osmotic agents
  • Saline laxatives: Magnesium, sulfate, potassium and phosphate salts
  • Poorly absorbed sugars: Lactulose, sorbitol, mannitol, lactose, glycerine suppositories
  • Polyethylene glycol (PEG): PEG 3350 laxative
Stimulant laxatives
  • Surface-active agents: Docusate, bile salts
  • Diphenylmethane derivatives: Phenolphthalein, bisacodyl, sodium picosulfate
  • Ricinoleic acid: Castor oil
  • Anthraquinones: Senna, cascara sagrada, aloe, rhubarb
  • Emollients
  • Mineral oil
Neuromuscular agents
  • 5-HT4 Agonists: Cisapride, or cisapride, prucalopride, tegaserod
  • Colchicine
  • Prostaglandin agent – Misoprostol
  • Cholinergic agents – Bethanechol, neostigmine
  • Opiate antagonists – Naloxone, naltrexone
Investigational agents
  • Recombinant methionyl human brain-derived neurotrophic factor (r-metHuBDNF), neurotrophin-3
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Bulk Laxatives

Fiber

  • Constipation has been associated with a deficiency of dietary fiber in Western society for decades. A correlation between increasing the daily fiber intake and fecal weight, as well as colonic transit time, has been demonstrated.
  • Dietary fiber appears to be effective in relieving mild to moderate, but not severe constipation. The recommended amount of dietary fiber is 20 to 35 grams per day (g/d) and this can be obtained from whole wheat bread, unrefined cereals, citrus fruits, and vegetables.
  • Insoluble fiber, such as cereal bran, may cause significant abdominal gas and bloating, creating discomfort. In some patients, these agents also delay gastric emptying and depress appetite. To improve the tolerance and adherence you may start with low doses of fiber and increase their dietary fiber intake gradually over the next weeks until ∼20 to 25 g/d.
  • If constipation has not improved, then commercially available fiber supplements should be tried. Patients also must be encouraged to drink water and maintain hydration when increasing fiber intake.

Ispaghula (Psyllium)

  • Ispaghula comes from an Asian plant that has a high water-binding capacity and is fermented in the colon. In an observational study with psyllium, the response to treatment was poor among patients with slow colonic transit, whereas 85% of patients without abnormal physiology improved or became symptom-free.
  • Side effects include delayed gastric emptying and loss of appetite in some patients. Also, there have been some reports of serious acute allergic reactions, cough, and asthma.

Methylcellulose

  • Methylcellulose is a synthetic fiber polymer that is methylated. This results in resistance to bacterial fermentation. Mainly, it absorbs water into the colonic lumen, which increases fecal mass promoting motility and reduction in the colonic transit time.
  • In one study, the patients showed an increase in solid stool mass with 1, 2, and 4 g of methylcellulose per day, but fecal water increased only with the 4-g dose. Despite the fact that bowel frequency was increased, the patients did not report a marked improvement in the consistency or passage of stools.

Calcium Polycarbophil

  • Calcium polycarbophil is a hydrophilic resin that is resistant to bacterial degradation and thus may be less likely to cause gas and bloating. In patients with IBS with features of constipation, calcium polycarbophil seems to improve overall symptoms and passage of stool, but not abdominal pain.

Osmotic Agents

  • In patients unresponsive to bulk agents alone, the addition of other laxatives is often the next step in the management of constipation. There are different forms of laxatives that can be selected based on the patient’s symptoms and preferences.

Poorly Absorbed Ions-H2

Magnesium and Sulfate

  • Magnesium, sulfate, and phosphate ions are poorly absorbed by the gut and thereby create a hyperosmolar intraluminal environment. Magnesium oxide has been considered safe to use on a regular basis in mildly constipated patients. Standard doses of 40 to 80 mmol of magnesium ion usually provoke a bowel movement within 6 hours. Magnesium sulfate is a more potent laxative that tends to produce a large volume of liquid stool and abdominal distention.Tas a result of excessive use.

Sodium sulfate is a component of some bowel lavage solutions for colon cleansing prior to diagnostic and surgical procedures,[ but significant absorption may occur in the jejunum that may cause electrolyte disturbances.

Phosphate

  • Phosphate can be absorbed by the small intestine, and a high dose must be ingested to produce an osmotic laxative effect. Complications have been reported with sodium phosphate and OTC use is no longer available in the United States.
  • Some of the complications reported include hyperphosphatemia, especially in patients with renal insufficiency and acute renal injury if used in large amounts as in bowel preparations. Risk factors include advanced age, dehydration, and the use of angiotensin-converting enzyme inhibitors or nonsteroidal anti-inflammatory drugs.

Poorly Absorbed Sugars

Lactulose

  • Lactulose is a poorly absorbed synthetic disaccharide of galactose and fructose. This nonabsorbable carbohydrate becomes a substrate for colonic bacterial fermentation that produces hydrogen and methane and lowers fecal pH, carbon dioxide, water, and fatty acids.
  • These products are osmotic agents that promote intestinal motility and secretion. The recommended dose of lactulose for adults is 15 to 30 mL once or twice daily. The time to onset of action is between 24 to 72 hours, longer than for other osmotic laxatives.
  • Lactulose increases stool frequency in chronically constipated patients and is dose-dependent because it is fermented by colonic bacteria, gas and bloating usually limit its clinical use.

Sorbitol

  • Sorbitol is a poorly absorbed sugar alcohol that may produce effects similar to lactulose if taken in sufficient dosages. Sorbitol is commonly found as an artificial sweetener. It has been shown that as little as 5 g can cause a rise in breath hydrogen from bacterial fermentation, and 20 g produces diarrhea in about half of normal patients.
  • Sorbitol is as effective as lactulose and less expensive. A randomized, double-blind, crossover trial of lactulose (20 g/d) and sorbitol (21 g/d) showed no difference in regards the frequency of bowel movements and patient preference. Patients using lactulose had more nausea compared with sorbitol. Mannitol is another sugar alcohol that can be used as a laxative.

Polyethylene Glycol

  • Polyethylene glycol (PEG) is an isosmotic laxative that is metabolically inert, which binds to water and keeps water retention inside the lumen. PEG is commonly used in solutions for colon cleansing as polyethylene glycol electrolyte lavage solutions (PEG-ELS) and sulfate-free electrolyte lavage solution (SF-ELS).
  • These solutions have electrolytes added to avoid side effects from dehydration and electrolyte disturbances and have been shown to be safe for preparation for diagnostic colonoscopy, barium x-ray examinations, and colon surgery. Most of these solutions have been shown to be dose-dependent, increasing the number of stools with increasing dosage of PEG. Low-dose PEG has been shown in studies to be more effective than lactulose in the treatment of chronic constipation.
  • The most common adverse effects of PEG include abdominal bloating and cramps. However, there are some case reports of severe pulmonary edema that have been reported with the use of PEG.

Stimulant Laxatives

  • Stimulant laxatives – increase intestinal motility and intestinal secretion. They begin working within hours and often are associated with abdominal cramps. Stimulant laxatives include anthraquinones (e.g., cascara, aloe, senna) and diphenylmethanes (e.g., bisacodyl, sodium picosulfate, phenolphthalein).
  • Castor oil – is used less commonly because of its side-effect profile and poor palatability. The effect of stimulant laxatives is dose-dependent. Low doses prevent absorption of water and sodium, whereas high doses stimulate secretion of sodium, followed by water, into the colonic lumen.
  • Stimulant laxatives – sometimes are abused, especially in patients with an eating disorder, even though at high doses they have only a modest effect on calorie absorption. Although a cathartic colon (i.e., a colon with reduced motility) has been attributed to prolonged use of stimulant laxatives, no animal or human data support this effect. Rather, cathartic colon, as seen on a barium enema examination, is probably a primary motility disorder.

Anthraquinones

  • Anthraquinones, such as cascara, senna, aloe, and frangula, are produced by a variety of plants. The compounds are inactive glycosides that when ingested, pass unabsorbed and unchanged down the small intestine and are hydrolyzed by colonic bacterial glycosidases to yield active molecules.
  • These active metabolites increase the transport of electrolytes into the colonic lumen and stimulate myenteric plexuses to increase intestinal motility. The anthraquinones typically induce defecation 6 to 8 hours after oral dosing.
  • Anthraquinones cause apoptosis of colonic epithelial cells, which they are phagocytosed by macrophages and appear as a lipofuscin-like pigment that darkens the colonic mucosa, a condition termed pseudomelanosis coli. Whether anthraquinone laxatives given over the long term cause adverse functional or structural changes in the intestine is controversial.
  • Animal studies have shown neither damage to the myenteric plexus after long-term administration of sennosides nor a functional defect in motility. A case-control study in which multiple colonic mucosal biopsy specimens were examined by electron microscopy showed no differences in the submucosal plexuses between patients taking an anthraquinone laxative regularly for one year and those not taking one. An association between use of anthraquinones and colon cancer or myenteric nerve damage and the development of cathartic colon has not been established.

Diphenylmethane Derivatives

  • Diphenylmethane compounds include bisacodyl, sodium picosulfate, and phenolphthalein. After oral ingestion, bisacodyl and sodium picosulfate are hydrolyzed to the same active metabolite, but the mode of hydrolysis differs. Bisacodyl is hydrolyzed by intestinal enzymes and thus can act in the small and large intestines. Sodium picosulfate is hydrolyzed by colonic bacteria.
  • Like anthraquinones, the action of sodium picosulfate is confined to the colon, and its activity is unpredictable because its activation depends on the bacterial flora.
  • Like the anthraquinone laxatives, bisacodyl leads to apoptosis of colonic epithelial cells, the remnants of which accumulate in phagocytic macrophages, but these cellular remnants are not pigmented. Aside from these changes, bisacodyl does not appear to cause adverse effects with long-term use.
  • Phenolphthalein inhibits water absorption in the small intestine and colon by effects on eicosanoids and the Na+/K+-ATPase pump present on the surface of enterocytes. The drug undergoes enterohepatic circulation, which may prolong its effects. It has been removed from the U.S. market because it is teratogenic in animals.

Ricinoleic Acid (Bisacodyl and Castor Oil)

  • Castor oil comes from the castor bean. After oral ingestion, it is hydrolyzed by lipase in the small intestine to ricinoleic acid, which inhibits intestinal water absorption and stimulates intestinal motor function by damaging mucosal cells and releasing neurotransmitters. Cramping is a common side effect.
  • Stimulant laxatives, such as bisacodyl and senna exert their primary effects through alteration of electrolyte transport by the intestinal mucosa and generally work within several hours. In his classification, Schiller refers to this class of drugs as “secretagogues and agents with direct effects on the epithelial, nerve, or smooth muscle cells.” Following their use, it is not uncommon for patients to report symptoms of abdominal discomfort and cramping. This grouping includes surface-active agents, diphenylmethane derivatives, ricinoleic acid, and anthraquinones.
  • Although stimulant laxatives may be associated with occasional side effects such as salt overload, hypokalemia, and protein-losing enteropathy, data does not support the theory that they cause a so-called cathartic colon. Melanosis Coli, pigmentation of the colonic mucosal due to the accumulation of apoptotic epithelial cells phagocytosed by macrophages, may develop in patients who chronically ingest anthraquinone-containing stimulant laxatives.
  • Despite prior theories to the contrary, neither anthracoid laxative use nor macroscopic or microscopic melanosis coli are associated with any significant risk for the development of colorectal adenoma or carcinoma.
  • Phenolphthalein, no longer marketed in the United States, has been associated with the fixed-drug eruption, protein-losing enteropathy, Stevens-Johnson syndrome, and lupus reactions.Castor oil, containing ricinoleic acid, alters intestinal water absorption and motor function, and side effects often include cramping and nutrient malabsorption.

Docusate Sodium

  • Docusate sodium is a widely available stool softener and is a detergent agent that stimulates fluid secretion by the small and large intestine. Like most available OTC agents, conflicting evidence supports its use.
  • One study showed no change in the volume of stool output in patients with ileostomy or weight of stool in normal subjects. A small double-blind crossover study showed improvement in bowel frequency in one-third of the studied patients. Other studies showed docusate to be less effective than psyllium for chronic idiopathic constipation.

Emollients

  • Mineral oil is an indigestible lipid compound which provides lubrication and emulsification of the fecal mass. In addition to being unpalatable, long-term use can cause malabsorption of fat-soluble vitamins, seepage, incontinence, and rarely lipoid aspiration pneumonia.

Enemas and Suppositories

  • Enemas general act by causing rectal distention and sometimes irritation of the rectal mucosa. Although generally safe, enemas may cause serious damage to the rectum by misinsertion resulting in trauma to the rectal mucosa.

Phosphate Enemas

  • Commercially available sodium phosphate enemas are hypertonic solutions, which cause stimulation and some degree of macro and microscopic irritation of the rectal mucosa. Like most other OTC agents, there is little convincing evidence of their efficacy, mostly because of the lack of well-designed trials.

Saline, Tap Water, and Soapsuds Enemas

  • Saline, tap water, and soapsuds enemas also cause rectal distention, prompting an evacuation. As a group, they are less irritating to the rectal mucosa if used in small volumes. With larger volumes, water intoxication has been reported with tap water enemas.
  • Similarly, electrolyte disturbances have also been reported with larger volume soapsuds enemas. Saline enemas have been proposed as a survival technique in situations without pure freshwater.

Stimulant Suppositories and Enemas

  • Glycerin and bisacodyl are available without a prescription as suppositories for use in constipation. Glycerin appears to work by stimulating an osmotic effect in the rectum. Bisacodyl exerts its action on neurons in the rectum, prompting defecation. Few if any clinical trials support their use.

Prokinetic Agents (5-HT4 Agonists)

  • Prokinetic agents induce contractions in the gastrointestinal tract. Recently, most attention in the development of prokinetic agents has focused on the 5-HT4 serotonin receptor, given prior toxicities of drugs with other targets (metoclopramide and cisapride in particular).
  • Tegaserod showed particular promise in the treatment of chronic constipation, but was withdrawn from the U. S. market due to observed cardiovascular toxicities; however, it remains available in other parts of the world. Newer 5-HT4 agonists are under development and appear promising as treatments for chronic constipation.[,Unfortunately, prucalopride is not yet available in the United States.
  • TD-5108, also known as velusetrag, is also a full 5-HT4 agonist. It has shown promise in phase II studies as an agent for chronic constipation. Despite positive results of early studies published around 2007, no phase III studies have been published and there may be issues with tachyphylaxis that may limit its utility for chronic constipation.

Peripheral µ-Opioid Antagonists

Methylnaltrexone

  • Methylnaltrexone is a peripheral µ-opioid receptor antagonist that was U.S. Food & Drug Administration- (FDA-) approved in 2008 for opioid-induced constipation in patients with late-stage illness who receive opioids on a continuous basis. Most patients in clinical trials had limited life expectancy. Results are usually brisk, with almost half of patients having a bowel movement within 4 hours of the first dose. In the clinical trials, methylnaltrexone did not appear to precipitate opioid withdrawal.

Alvimopan

  • Alvimopan is FDA approved to hasten bowel recovery after surgery. Like methylnaltrexone, it is also a µ-opioid receptor antagonist. It may also be useful in opioid-induced constipation.

Other Agents

Clostridium Botulinum Toxin Type A (Botox)

  • Clostridium botulinum toxin has been used to relieve outlet dysfunction defecatory disorders. Usually, it is injected into the puborectalis muscle. Controlled trials are lacking and it is not FDA approved for this indication.

Bethanechol

  • Cholinergic agents have been used in the treatment of constipation. Bethanechol appears to be beneficial in patients whose constipation results from tricyclic antidepressants. Use outside of this setting lacks evidence of efficacy. Neostigmine is clearly beneficial in colonic pseudo-obstruction, but given the severity of side effects, its use in chronic constipation would likely be problematic or intolerable.

Colchicine

  • Colchicine is commonly used for constipation in practice. Again though, there is limited evidence in the form of quality clinical trials to support its use. One study did demonstrate increased bowel movement frequency, but patients treated with colchicine had more abdominal pain than controls.
  • Misoprostol is also used in treating chronic constipation, but given that its mechanism is probably similar to lubiprostone and its toxicities are likely greater, its regular clinical use is probably not warranted.

Newer Agents

Linaclotide

  • Linaclotide targets the guanylate cyclase C protein and is minimally absorbed. In clinical trials, it has been shown to be safe, well-tolerated, decrease abdominal pain, accelerate colon transit, and improve bowel function and CSBM. Despite recent high-profile publications demonstrating its efficacy, it is unclear when or if FDA approval will occur.

R-Manhunt-3

  • Another promising approach in the management of chronic constipation is targeting neurotrophins, a family of proteins that may induce nerve growth, nerve transmission, and consequently improve colonic and/or GI tract transit times. Thus far, the only agent studied is R-metHuNT-3 (recombinant human neurotrophic factor 3). It appears to offer improvement in gut transit but suffers from some significant toxicities (injection site reactions and paresthesias).

Alternative Treatment

Defecation Training

  • Defecation training may be helpful, but few specially trained instructors are available. The process involves teaching and supportive listening as well as the encouragement of progress in follow-up sessions. The basics are teaching patients not to suppress the urge to defecate, setting aside time for regular bowel habits, and correct body positioning while defecating (including raising the feet above the floor when using Western-style toilets).

Anorectal Biofeedback

  • Anorectal biofeedback can be similarly beneficial, but finding qualified therapists may be challenging. The process usually involves several sessions performed with either surface electromyogram (EMG) electrodes or an anorectal manometry catheter. Patients are taught coordinated movements to promote successful defecation. The process is usually beneficial—a pooled analysis estimated about two-thirds of patients improved, but insurance coverage usually is an obstacle to its use.

 Home Remedies For Constipation

Triphala powder or churna

  • This consists of three fruits – amla or Indian gooseberry, haritaki (Chebulic Myrobalan) and vibhitaki (Bellirica Myrobalan). It is a great laxative and helps to regulate digestion and bowel movements.

How to use

  • You can either have one teaspoon with warm water or. Mix the powder with honey either before going to bed or early in the morning on an empty stomach.

 Raisins (kishmish)

  • They are packed with fiber and act as great natural laxatives. This remedy also works wonders for pregnant women, without the side-effects of medication. Here are more reasons to eat raisins.

How to use

  • Soak a handful in water overnight.
    Have them first thing in the morning on an empty stomach.

Guavas (abroad or Peru)

  • They have soluble fiber in the pulp and insoluble fiber content in the seeds. They also help with the mucus production in the anus and with peristalsis (a series of contractions within the intestinal lining that helps the passage of food in the stomach). Don’t forget about these health benefits of guavas.

Lemon (nimbu) juice

  • It acts as a cleansing agent for the intestines, the salt content helps in quick and easy passage of stool.
  • This juice also is a great way to detox your body. Here are more reasons to add lemons to your diet.

How to use

  • All you need to do is mix one teaspoon of lemon juice in a glass of warm water.
  • Add a pinch of salt to the solution.
  • Drink this juice on an empty stomach to relieve constipation.

Figs (Anjeer)

  • Either dried or ripe, figs are packed with fiber and act as a great natural laxative.

How to use

  • For relief from constipation, boil a few figs in a glass of milk, drink this mixture at night before bed.
    Make sure the mixture is warm when you drink it.
    Using a whole fruit for this purpose is much better as compared to syrups that are available commercially.

Flaxseeds (Alsi)

  • They are known for their fiber content, and can very well help you when it comes to constipation.

How to use

  • You can mix flaxseeds in your cereal every morning.
    Or just have a handful with warm water early in the morning. More reasons they are great for health.

Castor oil (Arandi ka tel)

  • This has been used for centuries as a sure shot remedy for constipation and has properties that can kill intestinal worms.

How to use

  • If drinking a spoon of castor oil alone is not something you’d like to do, you could add a tablespoon of it in a warm glass of milk.
    Have this mixture at night before bed to relieve constipation. Did you know castor oil is great for your skin too?

Spinach (Palak)

  • This has properties that cleanse, rebuild and renew the intestinal tract. You can also reap in these 10 amazing health benefits of palak.

How to use

  • You can have about 100 ml of spinach juice mixed with an equal quantity of water twice daily.
    This home remedy is the most effective method to cure even the most stubborn cases of constipation.

Oranges

  • They are not only a great source of vitamin C but also have a large amount of fiber content.

How to use

  • Eating two oranges every day, once in the morning and once in the evening can provide great relief from constipation.
    Eat them without peeling off the white threads for added effect. Here’s how oranges keep you healthy.

Seed Mixtures

  • This is a great source of fiber and can help relieve constipation. This mixture not only provides the necessary fiber content to relieve constipation but it also helps in rejuvenating the intestinal walls.

How to use

  • -2-3 sunflower seeds, a few flaxseeds, til or sesame seeds and almonds ground together to a fine powder can help relieve constipation.
    -Have one tablespoon of this mixture every day, for a week.
    -You can add it to your salad or cereal every morning.

Diet tips to avoid constipation

  • In order to avoid and cure constipation, it is essential that you maintain healthy food habits. Here are a few changes you could make in your diet to cure constipation:
  • Avoid foods that contain white flour-like maida, white sugar, and other processed foods.
  • Eat light regular meals, and make sure you eat at least 3-4 hours before you go to bed. Regular meals not only keep constipation at bay.
  • Include fruits and vegetables into your daily diet.
  • Adding condiments like jeera, Haldi, and ajwain in your food while cooking it is a great way to help digestion.
  • Drink at least eight glasses of water every day. Make sure you have a glass of warm water every morning and before you go to bed.
  • Constipation is an entirely curable and manageable condition, all you need to do is keep some of these home remedies in mind and you should be well on your way to a happy morning.

Can constipation be prevented or avoided?

There are things you can do to reduce constipation. This includes:

  • Add more fiber to your diet – Adults should eat between 20-35 grams of fiber each day. Foods, such as beans, whole grains, fruits, and vegetables are high in fiber.
  • Drink more water – Being dehydrated causes your stool to dry out. This makes having a bowel movement more difficult and painful.
  • Don’t wait – When you have the urge to have a bowel movement, don’t hold it in. This causes the stool to build up.
  • Get physical – exercise is helpful in keeping your bowel movements regular.
  • Beware of medicines – Certain prescription medicines (especially pain medicines) can slow your digestive system. This causes constipation.
  • Talk to your doctor about how to prepare for this if you need these medicines.
  • Try warm liquids, especially in the morning.
  • Add fruits and vegetables to your diet.
  • Eat prunes and bran cereal.
  • If needed, use a very mild over-the-counter stool softener like docusate or a laxative like magnesium hydroxide. Don’t use laxatives for more than 2 weeks without calling your doctor. If you overdo it, your symptoms may get worse.
  • Talk to your doctor if you are being treated for certain diseases that are related to constipation. He or she may have additional guidance for lowering your risks.

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Laxatives to avoid or use with caution for elderly patients

LAXATIVE PRECAUTIONS
  • Docusate
• Lacks evidence for prevention and treatment of constipation (ie, no harm, but ineffective)
  • Magnesium
• Avoid in individuals with cardiac or renal dysfunction
  • Mineral oil
• Oral mineral oil should be avoided for older adults owing to concerns about aspiration (safer alternatives are available)
  • Soapsuds enema
• Risk of colonic mucosa irritation
  • Sodium phosphate enema
• As a purgative, avoid owing to serious electrolyte, renal, cardiovascular, and neurological concerns
• As a laxative, avoid in individuals with dehydration, renal impairment, cardiac dysfunction, or electrolyte disturbances
  • picosulfate, magnesium oxide, and citric acid
• Risk of electrolyte imbalance
• Avoid for patients with renal impairment (creatinine clearance < 30 mL/min)
  • Polyethylene glycol 3350 with electrolytes
• Avoid if the patient has impaired gag reflex, is prone to aspiration or regurgitation, is semiconscious, has a risk of electrolyte imbalance, has severe renal dysfunction (creatinine clearance < 30 mL/min), or has congestive heart failure

 

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References

Your relationship with your life partner is not good? Solution is here…

Your relationship with your life partner is not good? When you first met your girlfriend or wife, you probably felt you could fly. You were in seventh heaven. Those first feelings were strong, exciting, and passionate. You wanted to be together all the time; holding hands, kissing, cuddling, making love. But sooner or later, every couple experiences tough times in their relationship. You may have some communication problems or issues in the bedroom; it doesn’t matter. You should always keep in mind that any obstacles can be overcome. Every relationship demands work, hard work, but they should be filled with fun and love as well. If you know how to have fun together and how to love, you’ll get through any tough periods. These simple hacks will help you restore that spark that seems to be lost now.

1. Refocus

You may be focused on your partner’s bugs that irritate and annoy you. Instead of complaining about these defects, focus on the good features of your woman. Don’t try to change her, it never works. Try to figure out what you can do differently to change your relationship for the better. Stay away from criticism, blame, and disagreement. Imagine what kind of relationship you want to have, set future goals, and start gaining them.

2. Talk more and ask questions

Image result for Your relationship with your life partner is not good? Solution is here

You can be 100% sure you know everything about your woman. You’re wrong. All of us change over time. Your half is no exception. Think how much you both have changed since the first time you went on the first date. Pretty much, yeah? The only way to get to know your partner better is to talk more and ask questions. You shouldn’t be afraid of the questions you’ve never asked but wanted to. You can start discussing topics that seem unimportant now; you may find them pretty interesting. You can buy relationship books, read them together and discuss. There are a lot of options. Just start talking more.Image result for Your relationship with your life partner is not good? Solution is here

3. Have fun

You may have been together forever, but your life shouldn’t be boring. The everyday routine needs to be destroyed. Have more fun together; do something new, something that differs from your common rituals. You can explore new places, attend cooking/dance classes, or even try skydiving.

4. Surprise her

Women love flowers and sweets. Who said you can’t surprise her with a bouquet of flowers with no reason. Even small gifts make girls happy. Buy her different presents from time to time. If you can afford something more expensive like a diamond necklace or a romantic trip to Seychelles, she will be excited and remember your generous gift for a long time.

5. Start sexting again

When you and your half started your relationship, we’re sure, you were sexting all the time. You had passionate sex and wanted to do naughty things to each other every night. So, why don’t you start sexting again? This kind of messages may boost your desire and bring a new zest to your intimate life. You may be surprised to see how horny your woman turns after a couple of sexts.

6. Go “off the grid”

Today you probably can’t even imagine how life without your phone looks like. We spend so much time surfing the web and checking our Facebook, Twitter, and Instagram accounts. We’re touching our phones more often than we’re touching our partners. Go “off the grid” at least for a day. Go away together, or stay at home doing various stuff like cooking, watching movies, or just having sex all day long. You’ll see how fantastic life can be without social media.Related image

7. Express gratitude

Don’t take for granted those small everyday things she does like cooking meals, laundering, or cleaning the apartment. You may not even pay attention to this “unimportant” stuff. Start expressing gratitude. The two words “Thank You” influence your relationship as much as those three strong words “I Love You.” In a while, you’ll see how this simple and common phrase can take your life together to the next level.

Related image

Schedule Change Gabapentin; FDA Recomendation for gabapentin

Schedule Change Gabapentin is a medication that is structurally related to the inhibitory neurotransmitter GABA.  It does not bind to the GABA receptors but instead modulates the release of excitatory neurotransmitters, which participate in nociception.

The number of prescriptions being written for gabapentin — typically used to treat seizures and painful nerve diseases — is at an all-time high. According to a report by IMS Health, 57 million prescriptions for gabapentin were written in the United States in 2015, a 42% increase since 2011.

Schedule Change Gabapentin; FDA Recomendation for gabapentin

The medication has several off label uses as well such as migraine, hot flashes, fibromyalgia, and more. Adverse events associated with the drug include: jerky movements, loss of coordination, drowsiness, and dizziness. Higher doses can cause withdrawal symptoms such as seizures, suicidal ideation, and irritability.

Gabapentin is not scheduled as a controlled substance, meaning that the medication has little potential for addiction and abuse. However, the drug does show characteristics of various medications associated with misuse and addiction such as benzodiazepines, producing similar withdrawal syndromes and psychoactive effects.

According to the American Addiction Center, gabapentin has become a drug of abuse with users reporting effects such as euphoria, a marijuana-like high, and other users described their state after taking the medication to be zombie like. After hearing this information it led me to a discussion with a pharmacist that I work with prompting us to ask the question of whether or not gabapentin should have a schedule change.

What studies have been conducted?

Currently gabapentin is not scheduled as a controlled substance because when given as a monotherapy, it has very little abuse potential. However, when the drug is taken with other medications such as muscle relaxants, opioids, or various anxiety medications, gabapentin’s potential for abuse and addiction significantly increasing and ultimately gets those individuals high.

Abusing gabapentin is not a recent affair and goes all the way back to 2004, the year that the generic was released. A study was conducted at a Florida correctional facility, which surveyed inmates receiving gabapentin. Out of 96 prescriptions, only 19 were actually in the hands of an inmate that was actually prescribed that drug. Inmates reported crushing and snorting the pills in order to get high similar to that of cocaine. After this study was performed, gabapentin was removed from various correctional facilities and was no longer allowed to be dispensed to inmates.  In 2011, a significant increase in the number of individuals using gabapentin as a cutting agent in heroin was seen in a number of police reports across the country.

Another study examining the misuse and abuse of the drug gabapentin, obtained urine samples from a total of 323 patients who were being treated at various pain clinics and addiction centers found that 70 of those patients were taking Gabapentin without a prescription.

What’s going on currently?

As of December 1, 2016 the State of Ohio Board of Pharmacy requires all pharmacies, wholesalers, and physicians to submit the specified dispensing, personal furnishing, or wholesale sale information on all products containing gabapentin to the Ohio Automated Rx Reporting System.

What does this mean for the future?

Ohio has already acknowledged gabapentin as a drug of abuse that needs to be monitored and reported. As the number of individuals abusing gabapentin increases, more overdoses are being seen throughout the country along with an increased number of individuals enrolled into pain addiction clinics for gabapentin abuse. With this being said why is gabapentin still not seen as a controlled substance? What is your opinion on the matter?

References

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