The Spinal Column
The spinal or vertebral column is a collection of 24 vertebrae plus the sacral bone
These bones provide support and mobility for the torso while also protecting the
nervous system.
There are 4 distinct and different regions of the spinal column - the cervical,
thoracic, lumbar and sacral regions. Each contains a different number
of vertebrae which are structurally unique. These structural variations
make certain regions of the s pinal column more flexible while making
other regions more stable and less susceptible to injury.
When viewed from the rear the spine normally appears vertically straight . When viewed from the side, however, 4 separate spinal curvatures should be present. Both the cervical and lumbar regions naturally have a "C" shaped curvature, while the thoracic and sacral regions possess a reversed "C" shaped curvature. The angles of these curves play a crucial role in minimizing spinal biomechanical stresses which lead to spinal pain and greatly accelerated spinal degenerative processes.
The chiropractic doctor is an expert in spinal evaluation and rehabilitation. He or she is trained to identify even the slightest spinal abnormalities. Eliminating pain, inflammation and biomechanical stresses while increasing overall health and quality of life is what chiropractic care is all about.
Doctors of chiropractic are the only health care professionals whose primary training centers around the detection, treatment, and rehabilitation of spinal column disorders. Understanding the spine is the key to understanding why chiropractic doctors do what they do and why they obtain extraordinary results with a variety of different conditions.
The spine is a complex structure containing a number of associated muscles, ligaments, joints and nerves which commonly become irritated and injured. Extended sitting, repetitive motions, bad postural habits, mental stress, lack of exercise and inadequate nutritional intake are just some of the everyday stresses which accumulate to produce devastating effects on the spinal components.
Doctors of chiropractic are the health care leaders in providing safe, fast and effective relief for most spinal problems.
Posture
Proper posture simply refers to maintaining the body in a position which protects against excessive stresses which cause injury, while requiring a minimal amount of muscular effort to maintain. In other words, a comfortable position which will not irritate your spinal tissues.
Posture plays a significant role in the development of chronic conditions such as chronic back and neck pain. Poor posture is responsible for overstretching ligaments and other supportive spinal structures as well as exhausting spinal musculature, all of which quickly leads to the development of chronic spinal pain.
Learning and practicing proper postural habits will help reduce the likelihood of acquiring back and neck injuries, reduce spinal degeneration, and help keep your spine and body happy and healthy.Proper Seated Posture
Prolonged sitting is a frequent cause of back and neck pain. And while extended periods of sitting are best avoided, for many, it's a fact of life.
When sitting, it's important to keep the back straight, knees bent, and
head centered over the shoulders. Slouching forward may be
comfortable and allow the spinal muscles to relax but gradually overstretches
spinal ligaments, leading to back and neck pain among other problems.
We always encourage patients to maintain a "neutral spine" position at all
time is ideal.
Seat Backrest - The proper chair has a backrest which slightly inclines backwards. This has the effect of relaxing the spinal musculature and decreasing spinal discal pressure.
Armrests - Armrests provide support for the arms which helps to reduce the work load and stress on the trapezius and shoulder muscles. The armrest height should allow the forearms to comfortably rest while being low enough to go underneath tables or desks in the work area.
Lumbar Support - Having a lumbar support either built into the chair or inserting a portable lumbar support helps to maintain your natural lower back curve. These small supports are quite handy, effective and relatively inexpensive.
Seat Bottom Angle - The seat angle relative to the floor is more of a personal preference than an exact science, as long as a neutral spine can be maintained in comfort. In general, the more the seat bottom tilts forward the more extension of your lower back will occur to keep you in a neutral position.
Seat Height - The height of the seat should be so that it allows you to sit all the way back in the seat while your feet are still able to reach the floor. If they can't and you're stuck with the chair, use a footrest to remedy the problem.
In addition to the suggestions provided above, it's important to:
* be aware of your posture throughout the day and be sure to maintain a neutral spine -no slouching
* take mini breaks on a regular basis when in a prolonged position and remember to stretch
* have the right equipment and tools for working in a prolonged position, use ergonomically designed furniture and keep a lumbar support in your car for "chair crises"
Proper Standing Posture
Although standing is something we do everyday most of us have never really given "the art of proper standing" a second thought. Many people are actually unaware that their standing habits can contribute to their back and neck problems.
If you're one of those people, the following "general standing guidelines" should help you out.
General Rules For Standing
* maintain a straight spine rather than slouching to the side
* avoid slouching forward or hyperextending
* keep the chin up with the head centered over the shoulders
* keep the feet slightly less than shoulder width apart
* keep the knees slightly bent
* wear comfortable shoes and leave the heels at home
* avoid standing still for long periods of time, rather, sit down or move around
Proper Lying Posture
Approximately 1/3 of our life is spent lying in bed, on the couch, and on the floor. Like other positions, there is a right way and a wrong way to lie. For individuals suffering from pain, modifications may be necessary to obtain a "pain-free" position or a position which does not aggravate the pain.
Lying On Your Stomach
Extended periods of "stomach lying" should be avoided. This is because excessive stress is placed on the joints of the low back and because excessive rotation must take place in the neck. Neck pain, back pain, headaches, dizziness, as well as arm paresthesias are commonly experienced when in this position for an extended period of time. If you must lie in this position to relieve pain or for some other reason, keep one leg bent with the same side arm raised with approximately 90 degrees of flexion at the shoulder and elbow joints.
Lying On Your Back
Most people find lying on their back to be a relatively comfortable position. For individuals suffering from back problems, placing a folded pillow underneath the knees will help reduce tension in the lower back and make this position more tolerable. Some individuals may also find placing a small pillow or towel under their lower back to be helpful. This will help to maintain the natural curve of the lumbar spine.
Lying On Your Side
Lying on your side is a favored position by many individuals. It may also be a comfortable position that provides relief for individuals with back problems. It's important while in this position to have adequate support for the head and neck. A pillow which fills the gap between the head/neck and the bed should be used to keep the head and neck in line with the rest of the spine. Additionally, placing a pillow between the knees will help reduce lumbar and pelvic torsion. Women with larger hip and small waists will find a small pillow under the waist will prevent lateral bending of the spine while lying on the side.
Choosing A Pillow
Choosing a pillow which supports the cervical spine is extremely important, especially for those with neck or upper back problems as well as those with a history of headaches. There are a number of cervical pillows on the market, however, many of the inexpensive pillows (those under $20) are poorly designed with rigid foam which does not conform to the natural contours of the head and neck. Look for a cervical pillow which will contour to the shape and size of your head and neck while still providing support. Don't be scared to spend a little extra on a high quality pillow - it's well worth the money, and besides, it's something you'll use everyday.
WELLNESS CENTER
Ergonomics
Ergonomics is the applied science of designing and developing equipment, workstation layout and work strategies to best suit and protect the human body. The goal of ergonomics is to minimize fatigue, discomfort, injury and emotional stress.
It's important to recognize that even the most ergonomically correct environment will not prevent repetitive stress injuries if the body is simply overworked. The body has limitations with what it can withstand. Surpassing those limitations will most definitely result in injury.
Choosing The Right Chair
Prolonged sitting is a frequent cause of back and neck pain. And while extended periods of sitting are best avoided, for many, it's a fact of life.
When sitting, it's important to keep the back straight, knees bent, and head centered over the shoulders. Slouching forward may be comfortable and allow the spinal muscles to relax but gradually overstretches spinal ligaments, leading to back and neck pain among other problems. We always encourage patients to maintain a "neutral spine" position at all time is ideal.
Seat Backrest - The proper chair has a backrest which slightly inclines backwards. This has the effect of relaxing the spinal musculature and decreasing spinal discal pressure.
Armrests - Armrests provide support for the arms which helps to reduce the work load and stress on the trapezius and shoulder muscles. The armrest height should allow the forearms to comfortably rest while being low enough to go underneath tables or desks in the work area.
Lumbar Support - Having a lumbar support either built into the chair or inserting a portable lumbar support helps to maintain your natural lower back curve. These small supports are quite handy, effective and relatively inexpensive.
Seat Bottom Angle - The seat angle relative to the floor is more of a personal preference than an exact science, as long as a neutral spine can be maintained in comfort. In general, the more the seat bottom tilts forward the more extension of your lower back will occur to keep you in a neutral position.
Seat Height - The height of the seat should be so that it allows you to sit all the way back in the seat while your feet are still able to reach the floor. If they can't and you're stuck with the chair, use a footrest to remedy the problem.
In addition to the suggestions provided above, it's important to:
* be aware of your posture throughout the day and be sure to maintain a neutral spine -no slouching
* take mini breaks on a regular basis when in a prolonged position and remember to stretch
* have the right equipment and tools for working in a prolonged position, use ergonomically designed furniture and keep a lumbar support in your car for "chair crises"
Adjusting Your Monitor
Maintaining the correct monitor height will prevent many problems with your eyes, neck and upper back. A monitor improperly positioned can irritate neck musculature, alter the normal spinal curves, induce eyestrain and even initiate migraine headaches.
Monitor Distance - The monitor should be located directly in front of the area where you're positioned to view the monitor. The preferred distance from your eyes to the actual screen varies with the size of the monitor and the current resolution settings. A 17 inch monitor should be located no less than 20 inches away. For smaller monitors you may need to be a little closer and for larger monitors a little farther away.
Monitor Settings - In conjunction with setting up the ideal distance between you and your monitor you may additionally need to alter the monitors resolution, contrast and brightness settings. This will allow characters and images to display clearly preventing squinting and eyestrain. The settings will vary depending on the distance you are from the monitor, the background you have on your active screen, the amount and type of lighting at your workstation, and the quality of your vision.
Lighting and Glare - Improperly positioned lighting can also wreak havoc on your ability to comfortably view your monitors display. Solutions include moving your monitor, moving the lighting, closing blinds or curtains, adjusting your monitors brightness setting, installing an anti-glare screen on your monitor, changing your background color to a lighter color, or even taping paper or cardboard along the edges of the monitor to act as a "visor".
Monitor Height - The proper monitor height is vital in preventing gradual neck and upper back strain. The most effective way to determine correct monitor height is to sit correctly in your chair or where ever you view your monitor. Next, close your eyes and position your body and head in a neutral and comfortable position - your spine should be straight and head centered over your shoulders. Then, open your eyes and note at which point your eyes are initially focused on. This area should correlate to the center of your monitors screen or the part of the screen you view most frequently.
Proper Telephone Techniques
Spending prolonged periods of time on the telephone can lead to chronic neck, shoulder and upper back pain disorders. Using the proper techniques and equipment is key in preventing these problems from developing.
Phone Location - The telephone should be located close to the main working area such that it is easily reached without having to twist, bend or overly stretch.
Shoulder Rests - For individuals who like to have their hands free when on the telephone we highly recommend not using a shoulder rest extension on your receiver. This still requires you to cock your head in order to keep the receiver next to the ear. This position places stress on the supporting structures of the neck and can throw the neck out of alignment. Rather, purchase a headset device. They have become plentiful and fairly inexpensive.
Speaker Phone - Using a speaker phone allows for maximum flexibility to work while talking. However, for some this may not be appropriate such as during times that clarity, volume and professionalism are required. If this is the case, look into purchasing a headset.
Headsets - Headsets are the most versatile telephone utility. They enable you to work uninhibited while on the telephone and keep your body in an ergonomically safe position.
Writing Materials - Be sure to keep a pen and pad of paper near your telephone so messages can be immediately taken without changing position or straining to grab the appropriate materials.
Setting Up Your Workstation
Having a well planned, ergonomically designed workstation increases productivity, minimizes repetitive stress injuries, increases employee morale, and increases the bottom line. Since everybody has different tasks and different body types, no one workstation setup is ideal for everyone. There are, however, some basic guidelines that should be abided by when designing a workstation.
Space - There needs to be adequate space for you to comfortably accomplish all tasks required of you. If you're constantly running into others or cannot properly function due to lack of adequate space physical and emotional stress increases while productivity decreases.
Equipment - Having the proper equipment which has been designed for the task at hand is essential. Equipment should be compatible with other equipment and be ergonomically designed to conform to your specific duties. Chairs should move freely in the work area and fit under desks and tables, lighting should fully light all work areas while not reflecting off of monitor screens, and computers and monitors should fit desks properly so screens can be read in comfortable positions and computer discs can be inserted without getting on all fours under the desk.
General Layout - Plan ahead. If you know what tasks you will be performing and what equipment you need, draw a floor plan and include equipment, furniture and accessory placement. Be sure keep those items used most frequently within reach are nearby to minimize strain and twisting. Commonly used equipment and other materials should be within reach from your primary workstation position.
Accessories - Add stackable document holders, have your rolodex nearby, purchase telephone headsets and any other items which can help to organize your workstation and keep all important and frequently used materials within your reach.
Taking Mini-Breaks and Stretching
Taking small periodic breaks doesn't just allow you to have a mini-mental vacation from the constant reins of work, it's also an important opportunity to reduce built-up physical tension by stretching out your contracted and tensed body. Every 30 to 40 minutes your body needs to move, stretch and get out of any position that it's been stuck in.
Assuming that your working position is in the seated posture, the following stretches can be performed throughout the day, everyday, to keep your body happy and healthy. All stretches should be held for 15-30 seconds and performed 1-3 times, depending on the amount of time you have. Hold the stretch in a position in which you can feel the muscles comfortably stretch.
Important Note: Do not perform any exercise or stretch without the recommendation of a licensed health care professional. If performing exercises or stretches at the recommendation of a licensed health care professional, immediately discontinue and seek professional medical assistance should unusual or abnormal pain and/or discomfort arise. Any and all exercises, stretches or similar contained within or available from this website are meant only for active patients of our office who have been specifically advised to perform said exercises, stretches or similar.
Basic Neck Stretches
Eyes To The Sky - Extend your head backwards while allowing your mouth to open. Allowing your mouth to open allows for a greater stretch to the muscles of the anterior neck. If you experience any balance problems, stretch the neck in the seated position only.
Ear To Shoulder - With your head centered over your shoulders, drop one ear to the same side shoulder. You should feel the opposite side of your neck stretch. You may increase the stretch by applying pressure to the top of the head with your hand. Repeat on the opposite side.
Chin To Chest - Drop your head forward while tucking your chin in towards your neck. Place one hand on the top of the head and gently apply added pressure if you wish to increase the stretch. This stretch affects the posterior cervical musculature.
Lateral Torso Stretch - While seated, grasp the lateral thigh or armrest of the chair with your opposite side arm and rotate your torso by pulling with the hand. Repeat to the opposite side.
Anterior Torso Stretch - In a seated or standing position with your hands interconnected place them behind your head and neck. Then, squeeze your shoulder blades together and extend your back slightly.
Posterior Torso Stretch - In the seated position with your buttocks on the forward edge of the chair, spread your legs apart and lean your torso forward, between your legs. If your back and hamstring muscles are tight, you will feel them stretch during this movement.
These are just some of the many stretches which can and should be performed frequently.
Proper Lifting Techniques
The Squat Lift - Ideally, objects should be lifted via the squat lift. With the back relatively straight, the knees are bent so that low back stress is minimized. While this does not seem as easy or natural as simply bending forward at the waist it significantly minimizes the lower spinal stress which can lead to numerous injuries including intervertebral disc herniation. Also, keep the feet wide apart when lifting the object and be sure to keep the object as close to your body as possible.
When Bending The Knees Is Difficult - For individuals who cannot fully bend the knees in order to pick up objects some bending of the spine may be necessary. In these cases, be sure the object being lifting is not heavy and most importantly, be sure to keep the object as close to the body as possible. The farther the object is away from the body the greater the stress on the spine.
The Golden Rule of Lifting - As stated above, be sure to keep objects as close to the body as possible during the lifting and carrying of objects.
Repetitive and Heavy Lifting - Even when proper lifting techniques are used repetitive stress injuries to the spine will occur if objects are too heavy or lifting is done continuously to the point that the spinal musculature becomes fatigued. Never lift heavy objects alone - get assistance or use a dolly. Never lifting continuously to the point that spinal muscles become fatigued. This will dramatically increase the odds of sustaining spinal injury.
Pregnancy
Pregnancy is a unique time in a woman's life filled with new experiences, heightened excitement, mixing emotions, and significant physical changes. It's also a time filled with many unanswered questions.
The following links provide much of the basic and more complex, yet essential information that can assist the mother-to-be in her quest for a smooth uncomplicated pregnancy and a healthy baby.
Chiropractic Care
Regular chiropractic care is an integral part of the prenatal and postpartum care during pregnancy. It helps keep mom feeling good and assists her in coping with the physical stresses of an ever changing body.
Neuromuscular and Biochemical Changes During Pregnancy
During pregnancy, most women experience a number of neuromuscular and biochemical problems which respond favorably to gentle, safe, noninvasive chiropractic care. These include:
* release of the hormone relaxin causes muscle and ligament relaxation
o allows joints to more easily misalign
* increased weight gain
o increased demand and fatigue on spinal and pelvic muscles
o increased stress on spinal and pelvic ligaments
o increase in lumbar and thoracic spinal curves which further increase the above
o increased joint stress and thus occurrence of vertebral and sacroiliac joint misalignments
* change in weight distribution
o increased demand and fatigue on spinal and pelvic muscles
o increased stress on spinal and pelvic ligaments
o increase in lumbar and thoracic spinal curves which further increase the above
o increased joint stress and thus occurrence of vertebral and sacroiliac joint misalignments
The above changes primarily affect the pelvic and spinal ligaments, muscles, joints and other supportive soft tissues. These changes cause sprain/strains of pelvic and spinal structures, as well as alteration of the normal spinal curvatures and spinal biomechanics. The result is an increased stress on the body leading to pain and discomfort.
Chiropractic Treatment of the Neuromuscular and Biochemical Problems
Doctors of chiropractic can alleviate the uncomfortable symptoms arising from the muscular, ligamentous, and biomechanical stresses encountered during pregnancy. We accomplish this through the use of a number of highly specialized procedures and techniques:
* Gentle Spinal Adjustive Procedures - specifically designed for use in the pregnant female
o assist in maintaining a spine free from vertebral misalignments and fixations - optimizing spinal biomechanics
o keep pelvis and spine in correct position/posture
o assist in pain relief by (1) reflexively reducing pain levels, and (2) reducing spinal and pelvic stresses which produce soft tissue pain
o keep tissues and biomechanics functioning optimally to minimize complications during birth
* Therapeutic Exercises and Stretches - safe for use during pregnancy
o keep spinal musculature strong, balanced, and pain-free
o enable spinal muscles to maintain the spine and body in a neutral, correct posture
o keep mom active and mobile
* Soft Tissue Work - massage, trigger point work, soft tissue mobilization, etc.
o keep muscles relaxed and flexible
o reduces bouts of muscle aches and pains
o reduces spinal stress
* Dietary and Nutritional Counseling - unique to the pregnant mother
o prevent neural tube and other birth defects
o increase the chances for a healthy baby
o assist the mother in maintaining optimal energy levels
o keep mother happy and healthy during stressful periods
* General Pregnancy Information - general info on pregnancy
o answer mother's questions
o improve mother's health
o optimize birthing process
o enhance baby's health
Frequently Asked Questions
Is Chiropractic Care Safe During Pregnancy?
Chiropractic care during pregnancy is safe for both mother and fetus. Spinal adjustments are especially gentle during pregnancy as far less force is required to correct subluxations. This is due to the increase in hormones causing significant muscle and ligamentous relaxation. Special "adjustive" positions are also used to provide comfort and safety for both mom and fetus.
How Often Should I Receive Chiropractic Care During My Pregnancy?
The frequency of care varies for a number of different reasons. Typically, regular care during a non-complicated pregnancy will range from once per week to once per month.
Chiropractic and Pregnancy Scientific Studies
Low Back Pain During Pregnancy
In this study, researchers identified the sacroiliac joints of the pelvis (frequently "adjusted" by chiropractors) as being responsible for the majority of low back pain cases in pregnancy. This is due to the significant number of hormonal and biomechanical changes occurring in the pelvis during pregnancy. Researchers found 7/10 women were helped by spinal manipulation in this study.
1. Bery G, Hammar M, Moller-Nielsen J et al. Obstet and Gynecol, 72:71-75, 1988.
TextBook on Chiropractic & Pregnancy
According to Dr. Fallon, author and internationally recognized "chiropractic pediatrician", statistics from her office "have demonstrated that chiropractic adjustments effectively reduce the average amount of time spent in labor." Her data shows a nearly 25% reduction in the average labor times in those receiving chiropractic care versus the generally accepted average labor time - in women who had given birth in the past, there was a 33% reduction in average labor time.
1. Fallon J. International Chiropractic Association. 1994 - Arlington, Virginia.
Italian Study on Chiropractic & Pregnancy
Postpartum pain was relieved in 90 of 120 patients who received chiropractic adjustments.
Back Pain
Common Causes of Back Pain During Pregnancy
Back pain is the most common soft tissue complaint pregnant women generally encounter. There are a number of reasons for this, including:
* increased ligament laxity due to the release of the hormone relaxin
* increase in weight gain and forward weight bearing
* poor body mechanics and postural habits
* ribcage enlargement increasing rib subluxations
* nerve and vascular impingement from mechanical pressure
The above factors increase the frequency of vertebral subluxations, muscular spasms, soft tissue pain and altered spinal biomechanics - all of which respond exceptionally well to regular chiropractic care.
Chiropractic Treatments
Spinal Adjustments
Spinal adjustments are safe, natural treatments chiropractors use to successfully manage soft tissue abnormalities in pregnancy. The adjustments are used to treat muscular, ligamentous, joint and neurological problems of the neck, back, pelvis and extremities. They help alleviate pain originating from the spinal and pelvic regions, reduce muscle spasm and tightness, correct biomechanical stresses, and keep the nervous system free from irritation and impingement. Chiropractic spinal adjustments are a safe and successful adjunct to any prenatal care program.
Soft Tissue Work
Muscles frequently become fatigued, irritated, spasmed and achy during pregnancy for the reasons previously mentioned. Chiropractic doctors utilize various soft tissue techniques such as trigger point work, soft tissue mobilization and massage to keep muscles relaxed, healthy, and functioning optimally.
Stretches and Exercises
Therapeutic stretches and exercises are an excellent way to keep the pregnant body flexible, strong and mobile. Chiropractic doctors utilize these therapies to assist the muscles in coping with the increased demands caused by the sudden weight gain and change in weight distribution - which fatigues and irritates unconditioned muscles. Keeping the pregnant body strong and flexible increases comfort and improves the likelihood of having a successful pregnancy.
Proper Body Mechanics and Postural Practices
Sudden weight gain and altered weight distribution also lead to a number of improper postural and biomechanical habits. Improper postural and mechanical habits further increase spinal and pelvic stress which increase tissue irritation and produce frequent bouts of pain and discomfort. Chiropractors focus on teaching proper postural habits and body mechanics to minimize stress on the body, minimize the risk of injury and keep mom functioning optimally and without discomfort throughout her pregnancy. To see the proper standing posture, click here or continue to scroll down.
Special Orthopedic Supports
Certain orthopedic supports and other products may be beneficial during pregnancy. This includes orthotics for the feet and certain orthopedic belts specifically designed for pregnancy (i.e. maternity belts, trochanter belts, etc.).
Proper Posture During Pregnancy
Proper Posture
* keep the head and chin up and the ears centered over the shoulders
* focus on keeping the abdominal muscles toned to keep back slightly flattened-avoid hyperextending
* widen stance and keep weight on center of each foot
* keeping the knees slightly bent reduces tension in the lower back
* keep shoulders slightly up and back
Improper Posture
* relaxed and weak abdominal muscles allow the pelvis to tilt forward
* head and chin are lowered and the ears are not centered over the shoulders
* knees locked in full extension increases the tension in the lower back
* shoulders are allowed to roll forward and down
* do not place weight on inner aspects of the feet
Prenatal Care
Chiropractic adjustments quicken recovery time and assist the body in normalizing overall pelvic and spinal biomechanics. Prenatal care during pregnancy assists mom in having a successful pregnancy and birth. It keeps mom and baby healthy and provides mom with needed physical and emotional support.
* The Birthing Plan
* Regular Chiropractic Adjustments
* Proper Diet and Nutrition
* Exercise / Physical Activity Program
* Soft Tissue Work
The Birthing Plan
Developing a birth plan plays an important role during the prenatal period. It is a written plan which outlines the wishes and wants of the mother in relation to procedures to be followed and actions to take during the prenatal period, during the birth and postpartum. The more detailed and specific the birth plan is, the more likely a successful outcome will be achieved. The following list includes many of the points which should be addressed and determined early on in pregnancy:
* Choice of caregiver
o obstetrician
o certified nurse-midwife
o lay midwife
* Other Practitioners
o chiropractor
o pediatrician
o massage therapist
o acupuncturist
* Birth Venue
o hospital birthing rooshared/stockpages/cp/wellness/pregnancy/m/chair delivery room
o home
o birthing center
* Prenatal care
o frequency of visits (primary care giver & chiro care)
o what do you do at visits
* Prenatal testing
o ultrasound frequency - abdominal vs. transvaginal (should always be performed by an ultrasonographer)
o amniocentesis
o CV sampling
o alfa-feto protein tests - to identify neural tube defects
o non-stress test
o other blood tests
* Levels of activity during the pregnancy
o working outside the home
o working in the home
o other children
o exercise
* What is your view on:
o anesthesia during birth
o what is your c-section rate
o how do you feel about vaginal birth after cesarean
o how do you feel about childbirth classes
o how do you feel about nursing
o how do you feel about testing in women over 30
* Labor
o how long to stay home before attending birth venue?
o how long can I labor before intervention?
o when would pitocin be used?
o level of monitoring during labor
o IV
o what positions can I assume?
o how mobile can I be?
o can I eat?
o under what circumstances would a c-section be performed?
o would you deliver a breech vaginal?
* Medications during labor
o epidural
o anesthesia
o IV drugs
* Birth
o can siblings be present?
o can my husband/labor support person be with me the whole time?
o how long can I push?
o what signals will you have to do a c-section?
o can I hold the baby directly after the birth before weighing etc.?
o will you be there the entire time?
o how often do you do an episiotomy?
* Postpartum
o can the baby room-in?
o who can visit the baby?
o what will the baby eat immediately after birth?
o can I begin to nurse immediately?
o frequency of visits?
o which pediatrician will see the baby?
o when can we go home after the birth?
o given a c-section, how long will I be in the hospital?
o should something be wrong with the baby, what type of services does the hospital offer?
1. Fallon J. TextBook on Chiropractic & Pregnancy. International Chiropractic Association. 1994 - Arlington, Virginia.
Regular Chiropractic Adjustments
Regular chiropractic adjustments play an integral role in the prenatal and postpartum periods. The adjustments help counter the effects of increased weight gain, altered weight distribution, and excessive ligament laxity. This keeps the spinal and pelvic regions healthy, biomechanically sound, and minimizes soft tissue irritation and discomfort.
Proper Diet and Nutrition
Maintaining a complete nutritious diet accompanied with supplementation is critical for mom's health and the health of the developing fetus. Making appropriate nutritional choices during pregnancy can be confusing but your chiropractic doctor can help guide you. Also, additional supplementation of prenatal vitamins and minerals is crucial; such as folic acid to prevent neural tube defects in your child.
Pregnancy requires an additional 300 calories per day in order to maintain metabolic homeostasis. Thus, those exercising should pay close attention to ensure adequate nutritional intake.
Exercise / Physical Activity Program
Except in special cases, mild to moderate physical activity and exercise during pregnancy is not only safe, but has been shown to be beneficial.
Kegel Exercises
Kegel exercises are extremely important for the pregnant woman. They function to improve and maintain pelvic floor muscular tone which is vital during pregnancy and delivery. These exercises are best initiated early in pregnancy and continued throughout the term of the pregnancy. This ensures that during the delivery process the pelvic musculature is able to withstand the changes taking place during labor. They're also important in decreasing the likelihood of tearing during delivery as well as the later development of hemorrhoids.
These exercises are performed by squeezing the muscles of the pelvic floor. This is done by contracting and holding the same muscles used to start and stop urination in midstream.
Exercise In Pregnancy Is Safe (For Mother and Fetus)
A recent study published in the American Journal of Obstetrics and Gynecology finds that women who exercised prior to their pregnancy can continue to do so without negatively affecting the fetus' growth or the pregnancy itself. According to the researchers, "Our results indicate that healthy and well-conditioned women may take part in exercise during pregnancy without compromising fetal growth and development as judged by birth weight or complicating the course of pregnancy or labor." Forty-two women participated in either a medium or high intensity exercise program throughout their pregnancy, including 6 weeks postpartum. The women exercised 6 times per week, participating in strength, interval and endurance training. All 42 women had been physically active prior to the pregnancy.
Overall, researchers discovered no differences between the high and medium intensity exercise groups in terms of labor, fetal birth weight, or the health of the infant immediately after birth. The researchers did note that women who exercised more gained more weight during pregnancy and went into labor earlier if they had a girl.
1. American Journal of Obstetrics and Gynecology 1998;178:280-286.
Exercise may protect against miscarriage
A study from the journal Epidemiology indicates that women who continue to exercise regularly during their pregnancy have a 40% lower risk of having a miscarriage of a chromosomally normal fetus compared with those who do not exercise. In the study, researchers interviewed 346 women who had suffered a miscarriage, asking them about exercise and other habits during their pregnancy. From these interviews, researchers were able to determine that exercise, such as swimming, jogging and aerobics, reduced the risk of miscarriage of a chromosomally normal fetus, but other physical activities such as housework, childcare or employment did not have this protective effect.
According to researchers, "The protective effect of exercise, but not of other forms of activity, may arise from the sustained aerobic nature of exercise; exertion during employment, housework and childcare is often sporadic." Of the women interviewed, approximately 25% claimed to have exercised during their pregnancy.
1. Epidemiology 1999;10:6-7, 73-75.
Athletes Can Work Out During Pregnancy
According to a case report in The Lancet, a 33 year old distance runner continued to exercise intensely throughout her pregnancy and gave birth to healthy twins, without complications. Throughout the woman's pregnancy, she ran an average of 66 miles per week with a heart rate of 130-140 beats per minute up until 3 days prior to giving birth. The researchers did warn that women who were inactive prior to their pregnancy would have to be more cautious.
1. The Lancet 1998;351:1182
Soft Tissue Work
Soft tissue work includes massage, trigger point work, soft tissue mobilization, and other soft tissue procedures. These techniques assist in keeping muscles and other tissues relaxed and flexible while reducing bouts of muscle aches and pains.
Stages of Fetal Development
* Conception
* Embryonic Development
* Fetal Development
Conception
* Formation of a viable zygote by the union of the male sperm and the female ovum; fertilization.
* Normal hormonal balance, normal cycle, healthy pregnancy.
* Normal gametes.
* Healthy fallopian tubes - normal conduction of ovum, no ectopic pregnancy.
* Healthy, normally positioned uterus, normal implantation.
Embryonic Development: 4-8 weeks of embryo development.
1.5 Weeks
Completely developed embryo.
2nd Week
Primitive streak.
3rd Week
Central nervous system begins to develop.
Heart development initiated - beating begins.
4th Week
Complete mass (baby and chorion, etc.) - about 1" long and the size of a pigeon's egg.
Embryo inside is about 3/8" and weighs less than 1 gram.
Outpouching from anterior brain - early eyes - limb buds of arms and legs.
5th Week
Nose and lips formation begins.
Brain is developed into 5 components and lumen of spinal cord is continuous with brain vesicles allowing free cerebral spinal fluid flow.
8th Week
Major organs begin development.
Now about size of hen's egg.
Embryo is 1" long and about 4 grams.
Hands and feet are seen.
Baby is extremely reactive to its environment.
Male sex hormone (testosterone) produced by testes
Masculine development in males - no change in females.
12th Week
Embryo is about the size of a goose egg.
Placenta is well established and weighs more than the baby.
Baby is approximately 3 1/2" long and weights about 60 grams (2 oz.). Fingers and toes can be seen.
This is the end of the embryonic stage.
Fetal Development
14-16th Weeks
Brain developed to the point that baby can suck, swallow and make irregular breathing movements.
16th Week
6", 6 oz. (180 grams)
Complete closure of nasal septum and palate.
Fetal heart beat heard with amplification.
Fetal movement is recognized.
Sex is distinguishable now.
Meconium formation in intestines.
20th Week
8", 10 oz. (300 grams).
Lanugo - fine hair covering over entire body, probably for protection of skin.
Vernix Caseosa - secreted by fetus, made of sebaceous material, and other materials and is probably protective.
Has some antimicrobial substances.
Fetal heart beat heard: 120-160 beats per minute.
24th Week
12", 1 1/2 lbs. (720 grams).
Baby is maturing, not considered viable (until 28 week).
28th Week
Baby can survive outside uterus if lungs capable of breathing.
10-20% survival if born at this time.
14", 2 1/2 lbs.
Viable (legally).
Fetus in breech position until 32nd week.
32nd Week
Maturing. 50% survival if born at this time.
Should turn to head down position.
16", 3 1/2 lbs. (1680 grams).
Skin is red and wrinkly.
The downy type hair is less plentiful and has more vernix.
30-34th Week
Baby is the same size as placenta.
36th Week
94% survival rate if born at this age.
18", 5 1/2 lbs.
Has some subcutaneous fat.
The baby stores things during this last trimester.
Mother should watch her weight at this time.
Fingernails are now at the tips of the fingers.
40th Week
Full term. 20", 7 lbs. (3360 grams).
Length is better indication of maturity of fetus.
Very little lanugo, lots of vernix.
Complications of Pregnancy
* Complications During Pregnancy
o Bell's Palsy
o Brachial Neuralgia
o Breast Cancer
o Carpal Tunnel Syndrome
o Coccydynia
o Ectopic Pregnancy
o Headaches
o Intercostal Neuralgia
o Meralgia Paresthetica
o Sciatica Neuralgia
o Teratology of Drugs and other Substances
o Toxemia of Pregnancy - Eclampsia
* Complications During Birthing Process
o Insufficient Power
o Passage Obstruction
o Baby Malpositions
o Forceps Delivery
o Cesarean Section
Complications During Pregnancy
Bell's Palsy
This condition involves a sudden onset of painless loss of facial muscle function. Lowering the eyebrows, closing the eye or pursing the lips is not possible. Patients may also experience a loss of taste in the anterior 2/3rd's of the tongue as well as pain posterior to the ear. While this condition has currently no known cause, many believe that vertebral subluxations are at least partly responsible.
Bell's palsy is 3 times more common in the pregnant women. Hormonal changes increasing water retention, grimacing during labor and delivery, as well as ligamentous laxity are primarily responsible. In the typical presentation, the woman awakes with a painless inability to operate the facial muscles on one side of the face. This typically occurs during the 3rd trimester. The condition tends to improve over the course of many weeks to months, depending on it's severity. Many studies have shown favorable results with chiropractic care.
Brachial Neuralgia
A large collection of nerves, the brachial plexus, from the cervical spine descend into each arm to provide sensory and motor innervation. Again, due to increases in hormonal factors, parts of the nerve plexus may become impinged or irritated. This results in radiating arm pain and may also be associated with neck pain or stiffness. Restoring cervical biomechanics and eliminating cervical subluxations is performed by the chiropractor to eliminate cervical stress and radicular symptoms.
Breast Cancer
Breast cancer is occurring earlier and earlier in women. Breast cancer occurs in approximately 1 out of every 3,000 pregnancies. It's important to have a breast examination prior to pregnancy or early on in the pregnancy to check for its presence and establish a baseline if present.
Carpal Tunnel Syndrome
Carpal tunnel syndrome, commonly associated with repetitive wrist movements, is also increased during pregnancy. This is because of hormonal changes which increases water retention, leading to increased pressure on the median nerve as it passes through the 'carpal tunnel' in the wrist, hence the name. Symptoms include numbness and tingling of the hand and fingers as well as achiness in the forearm and neck. Chiropractic adjustments applied to the cervical and wrist regions can help eliminate inflammation and quicken resolution. Additionally, vitamin B6 supplements have been shown to assist in eliminating the symptoms of carpal tunnel syndrome.
Coccydynia
This condition simply refers to a painful coccyx. The coccyx bone is located on the end of your sacrum or tailbone and can become irritated and painful in pregnancy. This is especially evident in the final trimester due to the position of the baby and the lack of room for the baby to maneuver. Manual adjustment of the coccyx is often required and can be safely and successfully performed by the chiropractor.
Ectopic Pregnancy
An ectopic pregnancy occurs when implantation and subsequent development of a fertilized ovum is outside the uterus. This most commonly occurs in a fallopian tube. As the embryo develops the fallopian tube is unable to expand like the uterus and can eventually rupture. Symptoms include cramp-like or stabbing pain in the lower abdomen. In 75% of the women vaginal bleeding will occur. This is a serious condition as acute internal hemorrhaging may occur leading to possible death.
Certain factors can increase the likelihood of ectopic pregnancies including:
* prior IUD use
* prior pelvic or tubal infection (certain STD's)
* tubal abnormalities
Headaches
Most headaches experienced during pregnancy are muscle tension headaches. These headaches are soft tissue and biomechanical in nature and respond excellent to chiropractic care. Fortunately for migraine headache sufferers, migraines are rare during pregnancy as hormones released counteract the processes involved that normally cause migraines.
Intercostal Neuralgia
Hormonal changes during pregnancy lead to the relaxation of ligaments and joint capsule which include the joints of the ribs. Additionally, increased weight gain increases the pressure on the rib cage. These two factors lead to increased rib subluxations and increased in intercostal nerve irritation. Chiropractors adjust the rib heads to alleviate nerve irritation and restore normal positioning of the rib heads.
Meralgia Paresthetica
This condition is a result of pressure on the lateral femoral cutaneous nerve which provides sensation to the skin of the upper lateral thigh. Increased abdominal weight and pressure as well as an increased lumbar curvature tend to place additional pressure in the area of the nerve which leads to pain, numbness and tingling in the area of the lateral upper thigh. Chiropractors commonly treat this condition successfully.
Sciatic Neuralgia
This common condition is a result of increased pressure on the large collection of nerves in the lower back. Symptoms include back pain with symptoms of pain, numbness and/or tingling radiating down the buttock and leg(s). There are also other causes of this condition which include sacroiliac joint dysfunction, lumbar disc syndrome, lumbar facet joint irritation, and vertebral subluxations. Chiropractic care is especially effective in treating sciatic neuralgia as the treatment directly addresses the cause.
Teratology of Drugs and other Substances
It's vital that all women who believe they may be pregnant or who are pregnant be 100% sure not to consume any drugs which may lead to birth defects or complications. It is estimated that 2-3% of all birth defects are drug-induced. One problem is damage to the embryo can occur early on prior to the woman knowing she is even pregnant. Vital systems such as the heart and nervous system develop in the embryo weeks after conception and are extremely susceptible to toxins such as drugs and alcohol.
Some common substances and drugs that can produce adverse effects on the growing embryo/fetus include:
* Artificial Sweetener - Aspartame
* Caffeine
* Aspirin
* Smoking
* Antihistamines
* Antibiotics
* Recreational Drugs (marijuana, cocaine, etc.)
* Antidepressant Drugs
* Antiepileptic Drugs
* Acne Drugs - accutane
* Cardiovascular Drugs
Toxemia of Pregnancy - Eclampsia
This fatal condition can develop in the 2nd half of pregnancy and has no known etiology, although some believe it results from poor nutrition. In the early stages (pre-eclampsia) signs include high blood pressure (hypertension), protein in the urine (proteinuria), and excessive edema (not always present). If eclampsia develops, the following may develop:
* epilepsy
* subarachnoid/cerebral hemorrhage
* preexisting brain tumors may fulminate
* uremia
* liver failure
* placental necrosis
* glomerular (kidney) and tubal necrosis
Complications During Birthing Process
Insufficient Power
Sufficient power and coordinated contractions are essential for a smooth uncomplicated labor. When the power of the contractions are weak or the pattern of contractions disorganized, the mother is more likely to become exhausted. This can cause fetal distress resulting in fetal harm and/or c-section. The following are causes of insufficient power or improper contractions:
* disordered uterine action
* colicky uterus
* constriction ring - Bandl's ring
* rigid cervix
* edematous cervix
* annular detachment
Passage Obstruction
Passage way obstructions (pelvic, uterine, cervix, etc.) can complicate the birthing process. These include:
* tumors
* cysts
* fractures
* subluxations
* flat male-like pelvis (android)
* physiological changes (degenerative joint disease, tuberculosis, rickets, osteomalacia)
Baby Malpositions
Malpositioning of the fetus can lead to abnormal birth presentations. Some of the more common malpositioned birth presentations include:
Upside Down Presentation - This presentation occurs in approximately 13% of births and involves a presentation where the baby presents in an "upside down" or "sunny side up" position. If the baby does not turn to the proper position or turns late, the newborn will generally develop "cone head". This position also produces what is known as "back labor". This can be significantly reduced in women who receive regular chiropractic care during their pregnancy.
Breech Presentation - In a breech presentation, the feet or buttock present first as opposed to the head. This presentation occurs in about 1 out of every 40 births. Possible complications can be serious and include:
* intracranial bleeding
* neck dislocation
* shoulder dislocation
* hip dislocation
* clavicle fracture
* internal organ disruption
* genital edema
* premature placental rupture
* prolapsed cord
* uterine rupture
Face Presentation - Face presentation occurs approximately every 3,000 births. In this presentation, the baby presents face first with the neck in extension. Causes include a lax uterus, flat pelvis, multiple fetus, anencephaly, or neck spasms of the fetus. This is stressful on the cervical spine and usually results in a cervical subluxation in the newborn. Chiropractic care by a chiropractor trained in adjusting newborns is crucial for the continued proper growth of the spine.
Shoulder Presentation - The shoulder presentation occurs in every 200-300 births and involves a "shoulder first" delivery. The causes include:
* twin birth
* hydramnios - excess of amniotic fluid
* placenta praevia - part of the uterus presents before the fetus due to placental malposition
* multiparity - a women who has had 3 or more children
* sub-septae uterus
* unusual fetal shape
* undue mobility of the pelvis
Forceps Delivery
In the event there is fetal or mother distress, or the labor is not going as planned, forceps assistance may be used. As forceps can cause a number of problems, forceps should only be used in absolutely necessary situations. The following injuries can result from improper/inappropriate forceps use:
* skull fractures
* birth marks
* doctor-induced torticollis
* brachial plexus damage
Cesarean Section
Although c-sections were becoming very popular a short while back, experts now recommend avoiding this procedure unless the mother or fetus are in extreme distress. This is due to the invasiveness of the procedure and unnecessary stresses placed on the baby. The indications for cesareans are:
1. placenta praevia - part of the uterus presents before the fetus due to placental malposition
2. fetal distress
3. maternal distress
4. failure for labor to progress
The Birthing Process
The time leading up to the normal birthing process is generally 266 days (38 weeks) - from conception to birth. However, only about 5% of births occur on the actual due date.
The 4 Stages of Labor:
Stage 1 - from the onset of labor to full cervix dilation
Stage 2 - from full cervix dilation to delivery of baby
Stage 3 - from delivery of baby to expulsion of placenta
Stage 4 - from expulsion of placenta to afterbirth recovery
Stage 1: Labor Onset to Full Cervix Dilation
Stage 1 consists of regular uterine contractions with cervix dilation. Full cervix dilation occurs at approximately 4 inches. The length of this stage varies from mother to mother. It depends on many factors including but not limited to previous pregnancies, the health and condition of the mother and fetus, patience of the doctor (or midwife) and willingness to induce labor, medications used at this stage, hospital versus home birth, etc.
Stage 2: Full Cervix Dilation to Delivery of Baby
Stage 2 generally takes from 15 to 50 minutes. During this time, uterine contractions strengthen and become more frequent. During this stage mother will feel the need to bear down and push. The baby goes through a series of passive movements - especially the head, which undergoes flexion, internal rotation, extension, external rotation, and crowning (the first sign of the baby's head).
Stage 3: Delivery of Baby to Expulsion of Placenta
This stage consists of the period immediately following birth to the expulsion of the placenta - generally taking 5 to 10 minutes. Should the placenta not easily come out, tugging or pulling should not be performed. Gentle uterine massage may be utilized to assist in the release. The placenta should always be examined to be sure no parts remain within the uterus. This can become detrimental to the mother causing hemorrhage and/or death.
Stage 4: Expulsion of Placenta to Afterbirth Recovery
During this stage, mother is monitored to be sure no uterine bleeding or other complications occur.
Postpartum
Chiropractic Care For Mother
After giving birth the woman once again undergoes many changes. Hormonal levels normalize, tissues shrink, and bones and joints shift. Throughout the pregnancy and birthing process, the woman's body has undergone many stressful events and some type of recovery/rehabilitation to reach pre-pregnancy state should be sought. Failure to restore normal biomechanics and tissue health can result in future problems in health and with future pregnancies. Chiropractic adjustments quicken recovery time and assist the body in normalizing overall pelvic and spinal biomechanics.
Chiropractic Care For Baby
Birth is generally a traumatic event for the baby. During the process, the body is "squeezed" through a relatively small opening compared to the size of the baby. This can result in serious injury which is not readily apparent, especially to the untrained eye. Chiropractic doctors can assess the spine for injuries which frequently occur during the birthing process. Immediate correction of vertebral subluxations and other abnormalities are necessary to prevent developmental problems for the child later in life.
Exercise/Weight Loss Program
A common complaint after birth is the excessive weight gained by the mother during pregnancy. While some women do not find it difficult to shed the extra pounds gained during pregnancy, this is generally not the case for most women. Beginning a weight loss and/or fitness program not only improves the mothers health and fitness levels, but also helps mothers deal with the increased energy and psychological demands of raising a family. Many chiropractors find weight loss and health programs an integral part of the treatment program.
Baby's Nutritional Requirements
Breast Feeding vs. Formula
It's important for the new mother to understand the significance breast milk has on their baby's health. A great number of studies have consistently shown babies fed breast milk (compared to formula) are significantly healthier with a much lower incidence of sickness from various infections and diseases.
Breast Feeding Reduces Infant Illnesses
A recent study has shown that breast feeding significantly reduces the occurrence of common infant illnesses such as respiratory tract infections, pneumonia, ear infections, and gastrointestinal disorders. In the 2 year study of 977 babies, a community program was implemented which urged women to breastfeed their infants rather than use baby formula. The program resulted in a significant increase in breastfed babies - 54.6%, up from 16.4%. During this time, the number of babies who developed pneumonia in the first year of life declined by 33% and the cases of gastroenteritis decreased by 15%.
According to researchers, their results suggest that "breast milk itself or the process of breast feeding provides protection against infant illnesses." The American Academy of Pediatrics recommends that mothers breastfeed their babies for at least one year, "and longer if mutually desired by the mother and child."
1. Pediatrics 1998;101:837-844.
Breast milk is better for premature infants
Experts believe breast milk contains a number of immune-boosting compounds which "jump-start" the infants immune system and assist the infant in fighting off infections. In this study, researchers found that preterm infants fed breast milk developed significantly fewer infections. 212 preterm, very low birth weight infants (under 3 pounds) were fed either breast milk or formula. After adjusting for all other factors, researchers determined that infants fed breast milk decreased their odds of infection by 57% - a dramatic decrease. Also, many immune system agents normally found in breast milk are in higher concentrations in the breast milk of mothers who deliver prematurely compared with mothers who delivery at term.
The American Academy of Pediatrics has long advocated the use of breast milk as the primary food source of newborn, full-term infants. In 1997, this advisory was extended to cover premature infants.
1. Pediatrics Electronic Pages 1998;102:e38.
Iron
According to the American Academy of Pediatrics, women should breast feed until at least 1 year of age and should not feed infants under 1 year cow's milk. Doing this can lead to a deficiency of iron. However, most baby formulas now contain added iron to prevent this from occurring.
Vitamin A
Vitamin A (retinol) is available in liquid form and is also added to most baby formulas. Occasional supplementation in infants and children is recommended if deficiency is suspected. Research has shown a single dose of 100,000 IU (International Units) in children under 12 months of age and 200,000 IU in children over 12 months of age can reduce the risk of death from measles and, according to a study on Brazilian children, can help treat severe diarrhea.
1. Butler JC, Havens PL, Sowell AL, et.al. Measles severity and serum retinol (vitamin A) concentration among children in the United States. Pediatrics 1993;91:1176-1181.
2. Barreto ML, Santos LM, Assis AM, et. al. Effect of vitamin A supplementation on diarrhea and acute lower-respiratory tract infections in young children in Brazil. Lancet 1994;322(Jul 23):228- 231.
Vitamin B's
Vitamin B is passed to the fetus and to the baby (via breast milk) by the mother. Thus, if the mother is deficient so to can the baby become deficient. In the case of mothers with vitamin B deficiencies (more common in vegetarians and vegans), supplementation may be necessary for mother and child.
Vitamin D
Vitamin D is another vitamin in which there may be a deficiency. Generally, a deficiency is most common when the mother is a vegetarian and/or lacks adequate sun exposure. In both cases, supplementation of the mother and infant is recommended. Also, mothers who breastfeed may spend 15 minutes in the sunlight daily to increase their vitamin D levels.
Vitamin K
In some infants and neonates, including those with certain malabsorption disorders, vitamin K deficiency may occur. This can lead to unexpected hemorrhagic disease (bleeding). Often, babies are give intramuscular vitamin K shots at birth to prevent this condition.
Zinc
Zinc deficiencies can occur in infants whose mothers are deficient in zinc or if there exists a problem with zinc uptake from the mammary glands in the mother's breasts. Zinc deficiencies are also common in premature infants and children with malabsorption syndromes. Zinc deficiencies are generally not found in infants who breastfeed, assuming the mother is not deficient. Signs of deficiency include:
* skin lesions (appear as diaper rash or candida)
* diarrhea
* growth failure
* alopecia (baldness)
* irritability
* anorexia
