title: Pontic Greeks

text: In the 1600s and 1700s, as Turkish lords called derebeys gained more control of land along the Black Sea coast, many coastal Pontians moved to the Pontic Mountains. There, they established villages such as Santa.


title: Pontic Greeks

text: Between 1461 and the second Russo-Turkish War of 1828–29, Pontic Greeks from northeastern Anatolia migrated as refugees or economic migrants (especially miners and livestock breeders) into nearby Armenia or Georgia, where they came to form a nucleus of Pontic Greeks which increased in size with the addition of each wave of refugees and migrants until these eastern Pontic Greek communities of the South Caucasus region came to define themselves as Caucasian Greeks.


title: Pontic Greeks

text: During the Ottoman period a number of Pontian Greeks converted to Islam and adopted the Turkish language. This could be willingly, for example so to avoid paying the higher rate of taxation imposed on Orthodox Christians or in order to make themselves more eligible for higher level government and regular military employment opportunities within the empire (at least in the later period following the abolition of the infamous Greek and Balkan Christian child levy or 'devshirme', on which the elite Janissary corps had in the early Ottoman period depended for its recruits). But conversion could also occur in response to pressures from central government and local Muslim militia (e.g.) following any one of the Russo-Turkish wars in which ethnic Greeks from the Ottoman Empire's northern border regions were known to have collaborated, fought alongside, and sometimes even led invading Russian forces, such as was the case in the Greek governed, semi-autonomous Romanian Principalities, Trebizond, and the area that was briefly to become part of the Russian Caucasus in the far northeast.


title: Pontic Greeks

text: Large communities (around 25% of the population) of Christian Pontic Greeks remained throughout the Pontus area (including Trabzon and Kars in northeastern Turkey/the Russian Caucasus) until the 1920s, and in parts of Georgia and Armenia until the 1990s, preserving their own customs and dialect of Greek.


title: Pontic Greeks

text: Between 1913 and 1923, the Turkish leadership attempted to expel or kill its native Greek population, including the Pontic Greeks. The genocide was first perpetrated by the Three Pashas and later by the rebel government under Mustafa Kemal. Different scholars have made different estimates for the death toll; most estimates range from 300,000 to 360,000 Pontic Greeks killed. Some notable victims include Matthaios Kofidis and Nikos Kapetanidis. Many were executed, for example during the Amasya trials; others were subject to massacres; many Pontic men were forced to work in labor camps until they died; still others were deported to the interior on death marches. Rape, primarily of Pontic women and girls, was prominent.


title: Pontic Greeks

text: In 1923, after hundreds of years, those remaining were expelled from Turkey to Greece as part of the population exchange between Greece and Turkey defined by the Treaty of Lausanne. In his book "Black Sea", author Neal Ascherson writes:


title: Pontic Greeks

text: According to the 1928 census of Greece, there were in total 240,695 Pontic Greek refugees in Greece: 11,435 from Russia, 47,091 from the Caucasus, and 182,169 from the Pontus region of Anatolia.


title: Pontic Greeks

text: In Turkey, however, together with Crypto-Armenians surfacing it has also given the Pontic community in Turkey more attention, estimates are up to 345,000


title: Pontic Greeks

text: During their millennia-long presence on the Black Sea's southern coast, Pontic Greeks constructed a number of buildings, some of which still stand today. Many structures sit in ruins. Others, however, enjoy active use; one example is Nakip Mosque in Trabzon, originally built as a Greek Orthodox church during the 900s or 1000s.


title: Pontic Greeks

text: Ancient Greeks reached and settled the Black Sea by the 700s BCE; Sinope was perhaps the earliest colony. According to the Pontic Greek historian Strabo, Greeks from the existing colony of Miletus settled the Pontus region. Some walls from an early fortification stand in the modern Turkish city of Sinop (renamed from Sinope). These fortifications may date back to early Greek colonization in the 600s BCE. During late Ottoman and recent Turkish times, the fortress housed a state prison.


title: Pontic Greeks

text: Between 281 BCE and 62 CE, the Mithridatic kings ruled the Pontos region and called it the Kingdom of Pontus. While the ruling dynasty was Persian in origin, many kings had Greek ancestry, as Pontic rulers often married Seleucid nobility. Some of these Persian/Greek rulers were interred in the Tombs of the kings of Pontus. Their necropolis is still visible in Amasya.


title: Pontic Greeks

text: One Pontic king, Pharnaces I of Pontus, may have built Giresun Castle in the 100s BCE. There's also a chance it was built during medieval times. From the castle, the Black Sea and much of Giresun are visible.


title: Pontic Greeks

text: Many other structures date back to Greek occupation in ancient times. Ancient Greeks inhabited Giresun, then called Kerasous, from the 5th century BCE. During this time, they must also have used Giresun Island. The poet Apollonius of Rhodes mentioned this island in his best-known epic, the "Argonautica." Altars on the island date to the Classical or Hellenistic period. Its use as a religious center continued after the rise of Christianity in the region. During Byzantine times, likely in the 400s or 500s, a monastic complex was built on the island, dedicated to either St Phocas of Sinope or Mary. It functioned both as a religious center and as a fortress.


title: Pontic Greeks

text: Many old Pontic Greek city-states remain in ruins. One is Athenae, an archaeological site near modern Pazar. It sat on the Black Sea coast and housed a temple to Athena.


title: Pontic Greeks

text: After Christianity spread to the Pontus region in Roman times, Pontic Greeks began constructing a number of churches, monasteries, and other religious buildings. The Virgin Mary Monastery in Şebinkarahisar District, Giresun Province may be one of the oldest Greek Orthodox monasteries in the region; Turkish archaeologists suspect it may date to the 2nd century. The monastery is made of carved stone and built into a cave. As of the mid-2010s, it's open for tourism.


title: Pontic Greeks

text: Other religious buildings were constructed later. Three ruined monasteries lie in Maçka, Trabzon Province: Panagias Soumela Monastery, Saint George Peristereotas Monastery, and Vazelon Monastery. These were built during early Byzantine times. Vazelon Monastery, for example, was built around 270 CE, and it retained great political and societal importance until its abandonment in 1922/3. While St. George Monastery (also called Kuştul Monastery) and Vazelon are abandoned, Sumela is a prominent tourist attraction.


title: Pontic Greeks

text: Pontic Greeks also constructed a number of non-religious buildings during Byzantine times. In the 500s, for example, a castle was built in Rize on the order of Justinian I. It was later expanded. The old fortress still stands today, serving tourists.


title: Pontic Greeks

text: Later, the Pontians built further churches and castles. Balatlar Church is a Byzantine church dating back to 660. It lies on the Black Sea coast. Despite vandalism and natural deterioration, the church still has old frescoes, which have been of interest to modern historians. The actual structure itself may date to Roman times. It likely had different uses over the centuries, potentially being a public bath and gymnasium before its use as a church. Pottery found at the site dates to the Roman and Hellenistic eras. There is also speculation that a piece of the True Cross was found at Balatlar Church; however, it's more likely that the materials found were actually the relics of a saint or other holy person.


title: Pontic Greeks

text: Trabzon has at least three more late Byzantine churches that stand today. St. Anne Church, as the name suggests, was dedicated to Saint Anne, the mother of Mary. While the actual date of construction is uncertain, it was restored by the Byzantine emperors in 884 and 885. It had three apses and a tympanum over the door. Unlike many churches in Trabzon, there is no evidence of it being converted into a mosque following Ottoman conquest in 1461.


title: Pontic Greeks

text: Two other structures in Trabzon, built as churches in Byzantine or Trapezuntine times, are now functional mosques. The New Friday Mosque, for example, was originally the Hagios Eugenios Church dedicated to Saint Eugenios of Trebizond. Another is Fatih Mosque. It was originally the Panagia Chrysokephalos church, a cathedral in Trabzon. The name is fitting; means "conqueror" in both Ottoman and modern Turkish.


title: Pontic Greeks

text: Another church, Trabzon's Hagia Sophia, was perhaps built by Manuel I Komnenos. It was used as a mosque after Turkish conquest; the frescoes may have been covered for Muslim worship. Hagia Sophia underwent restoration work in the mid-20th century.


title: Pontic Greeks

text: After European invaders sacked Constantinople in 1204, the Byzantine Empire fractured. The Pontus region went into the hands of the Komnenos family, who ruled the new Empire of Trebizond.


title: Pontic Greeks

text: During the Empire of Trebizond, many new structures were built. One is Kiz Castle in Rize Province. The castle sits on an islet just off the Black Sea coast. According to Anthony Bryer, a British Byzantinist, it was built in the 1200s or 1300s on the order of Trapezuntine rulers. Zilkale Castle is another fortress in Rize Province. According to the same historian, it may have been built by the Empire of Trebizond for local Hemshin rulers. Yet another fortress, the Kov Castle in Gümüşhane Province, may have been built by Trapezuntine Emperor Alexios III.


title: Pontic Greeks

text: Alexios III, one of the last emperors under whom the Empire of Trebizond flourished, built Panagia Theoskepastos Monastery in the 1300s. It was an all-female monastery in Trabzon. The monastery may undergo restoration work to boost tourism.


title: Pontic Greeks

text: After Mehmed the Conqueror lay siege to Trabzon in 1461, the Empire of Trebizond fell. Many church buildings became mosques around this time, while others remained in the Greek Orthodox community.


title: Pontic Greeks

text: Pontic Greeks continued to live and build under Ottoman rule. For example, Pontians in Gümüşhane established the valley town of Santa (today called Dumanlı) in the 1600s. Even today, many of the stone schools, houses, and churches built by Santa's Greek Orthodox residents still stand.


title: Pontic Greeks

text: They weren't divorced from Ottoman society, however; Pontic Greeks also contributed their labor to Ottoman construction projects. In 1610, Pontians built the Hacı Abdullah Wall in Giresun Province. The wall is long.


title: Pontic Greeks

text: Trabzon remained an important center of Pontic Greek society and culture throughout Ottoman times. A scholar named Sevastos Kyminitis founded the Phrontisterion of Trapezous, a Greek school operating in Trabzon from the late 1600s to the early 1900s. It was an important center for Greek-language education across the whole Pontus region. Some students came from outside of Trabzon to learn there (one example being Nikos Kapetanidis, who was born in Rize).


title: Pontic Greeks

text: After the Ottoman Reform Edict of 1856 guaranteed more religious freedom and civic equality for the Ottoman Empire's Jews and Christians, new churches were constructed. One of these was the church at Cape Jason in Perşembe, Ordu Province. Local Georgians and Greeks built this church in the 1800s; it remains today. Another was the small stone church in Çakrak, Giresun Province. Still another was Taşbaşı Church in Ordu, built in the 1800s; after the Greek Orthodox were expelled from Turkey, it saw some use as a prison. Many other less-notable churches remain throughout the Pontus region.


title: Pontic Greeks

text: Some of the old houses once belonging to Pontic Greeks still stand. For example, Konstantinos Theofylaktos, a wealthy Greek, had a mansion built for him in Trabzon. It now functions as Trabzon Museum.


title: Pontic Greeks

text: Many structures have not survived to the present day. One example of this is Saint Gregory of Nyssa Church, Trabzon, which was dynamited in the 1930s to make way for a new building.


title: Pontic Greeks

text: Some of the settlements historically inhabited by Pontian Greeks include (current official names in parenthesis):


title: Pontic Greeks

text: Ethnic Greeks indigenous to the high plateau of Eastern Anatolia to the immediate south of the boundaries of the Empire of Trebizond – essentially the northern portion of the former Ottoman Vilayet of Erzurum between Erzinjan and Kars province, that is the western half of the Armenian Highlands – are sometimes differentiated from both Pontic Greeks proper and Caucasian Greeks. These Greeks pre-date the refugees and migrants who left their homelands in the Pontic Alps and moved onto the Eastern Anatolian plateau after the fall of the Empire of Trebizond in 1461. They were mainly the descendants of Greek farmers, soldiers, state officials and traders, who settled in Erzurum province in the late Roman and Byzantine Empire period.


title: Pontic Greeks

text: Unlike the thoroughly Hellenized areas of the western and central Black Sea coast and the Pontic Alps, the Erzinjan and Erzerum regions were primarily Turkish- and Armenian-speaking, with Greeks forming only a small minority of the population. The Greeks of this region were consequently more exposed to Turkish and Armenian cultural influences than those of Pontus proper, and also more likely to have a strong command of the Turkish language, particular since the areas they inhabited had also been part of the Seljuk Sultanate of Rum and other pre-Ottoman Turkish powers in Central and Eastern Anatolia. Many are also known to have "turned Turk" in both the Seljuk and Ottoman periods, and consequently to have assimilated into Turkish society or reverted to Christian Orthodoxy in the 19th century. Erzurum province was invaded and occupied by the Russian Empire several times in the 19th and early 20th centuries, and large numbers of Eastern Anatolia Greeks are known to have collaborated with the Russians in these campaigns, particularly that of the 1828–29 Russo-Turkish War, alongside Pontic Greeks inhabiting areas to the immediate north of Erzinjan and Erzurum.


title: Pontic Greeks

text: As with Pontic Greeks proper, those Eastern Anatolia Greeks who migrated eastwards into Kars province, Georgia, Armenia and Southern Russia between the early Ottoman period and 1829 generally assimilated into the branch of Pontic Greeks usually called Caucasian Greeks. Those who remained and retained their Greek identity into the early 20th century were either deported to the Kingdom of Greece as part of the exchange of populations between Greece and Turkey in 1923-4 or massacred in the Greek genocide that occurred after the larger Armenian genocide in the same part of Anatolia.


title: Pontic Greeks

text: The culture of Pontus has been strongly influenced by the topography of its different regions. In commercial cities like Trebizond, Samsunda, Kerasounda, and Sinopi upper-level education and arts flourished under the protection of a cosmopolitan middle class. In the inland cities such as Argyroupolis, the economy was based upon agriculture and mining, thus creating an economic and cultural gap between the developed urban ports and the rural centers which lay upon the valleys and plains extending from the base of the Pontic alps.


title: Pontic Greeks

text: Pontic's linguistic lineage stems from Ionic Greek via Koine and Byzantine Greek with many archaisms and contains loanwords from Turkish and to a lesser extent, Persian and various Caucasian languages.


title: Pontic Greeks

text: The rich cultural activity of Pontian Greeks is witnessed by the number of educational institutions, churches, and monasteries in the region. These include the Phrontisterion of Trapezous that operated from 1682/3 to 1921 and provided a major impetus for the rapid expansion of Greek education throughout the region. The building of this institution still remains the most impressive Pontic Greek monument in the city.


title: Pontic Greeks

text: Another well known institution was the Argyroupolis, built in 1682 and 1722 respectively, 38 highschools in the Sinopi region, 39 highschools in the Kerasounda region, a plethora of churches and monasteries, most notable of which are the St. Eugenios and Hagia Sophia churches of Trapezeus, the monasteries of St. George and St. Ioannes Vazelonos, and arguably the most famous and highly regarded of all, the monastery of Panagia Soumela.


title: Pontic Greeks

text: During the 19th century hundreds of schools were constructed by Pontic Greek communities in the Trebizond Vilayet, giving the region one of the highest literacy rates in the Ottoman Empire. The Greeks of Caykara, who according to Ottoman tax records converted to Islam during the 17th century, were also recognized for their educational facilities. Teachers from the Of-valley provided education for thousands of Anatolian Sunni and Sufi students in home schools and small madrassas. Some of these schools taught Pontic Greek alongside Arabic (and to a lesser extent Persian or Ottoman Turkish as well). Although Atatürk banned these madrassas during the early republican period, some of them remained functioning until the second half of the 20th century because of their remote location. The effects of this educational heritage continue to this day, with many prominent religious figures, scientists and politicians coming from the areas influenced by the Naqshbandi Sufi orders of Pontic Greek extraction in Of, Caykara and Rize, among them president Erdogan, whose family originates from the village of Potamia.


title: Pontic Greeks

text: Pontian music retains elements of the musical traditions of Ancient Greece, Byzantium, and the Caucasus (especially from the region of Kars). Possibly there is an underlying influence from the native peoples who lived in the area before the Greeks as well, but this is not clearly established.


title: Pontic Greeks

text: Musical styles, like language patterns and other cultural traits, were influenced by the topography of Pontos. The mountains and rivers of the area impeded communication between Pontian Greek communities and caused them to develop in different ways. Also significant in the shaping of Pontian music was the proximity of various non-Greek peoples on the fringes of the Pontic area. For this reason we see that musical style of the east Pontos has significant differences from that of the west or southwest Pontos. The Pontian music of Kars, for example, shows a clear influence from the music of the Caucasus and elements from other parts of Anatolia. The music and dances of Turks from Black Sea region are very similar to Greek Pontic and some songs and melodies are common. Except for certain laments and ballads, this music is played primarily to be danced to.


title: Pontic Greeks

text: An important part of Pontic music is the Acritic songs, heroic or epic poetry set to music that emerged in the Byzantine Empire, probably in the 9th century. These songs celebrated the exploits of the Akritai, the frontier guards defending the eastern borders of the Byzantine Empire.


title: Pontic Greeks

text: The most popular instrument in the Pontian musical collection is the kemenche or lyra, which is related closely with other bowed musical instruments of the medieval West, like the Kit violin and Rebec. Also important are other instruments such as the Angion or Tulum (a type of Bagpipe), the davul, a type of drum, the Shiliavrin, and the Kaval or Ghaval (a flute-like pipe).


title: Pontic Greeks

text: The zurna existed in several versions which varied from region to region, with the style from Bafra sounding differently due to its bigger size. The Violin was very popular in the Bafra region and all throughout west Pontos. The Kemane, an instrument closely related to the one of Cappadocia, was highly popular in southwest Pontos and with the Pontian Greeks who lived in Cappadocia. Finally worth mentioning are the Defi (a type of tambourine), Outi and in the region of Kars, the clarinet and accordion.


title: Pontic Greeks

text: Popular singers of Pontic music include Stelios Kazantzidis, Chrysanthos Theodoridis, Stathis Nikolaidis, Theodoros Pavlidis, Giannis Tsitiridis, and Pela Nikolaidou.


title: Pontic Greeks

text: Pontian dance retains aspects of Persian and Greek dance styles. The dances called Horoi/Choroi (), singular Horos/Choros (Chorus) (), meaning literally "Dance" in both Ancient Pontian and Modern Greek languages, are circular in nature and each is characterized by distinct short steps. A unique aspect of Pontian dance is the tremoulo (), which is a fast shaking of the upper torso by a turning of the back on its axis. Like other Greek dances, they are danced in a line and the dancers form a circle. Pontian dances also resemble Persian and Middle Eastern dances because they are not led by a single dancer. The most renowned Pontian dances are Tik (dance), Serra, Maheria or Pyrecheios, Kotsari and Omal. Other, less common, dances include Letsina, Dipat, Podaraki, and Atsiapat.


title: Pontic Greeks

text: Pontic Greek history with organised sports began with extra-curricular activities offered by educational institutions. The students would establish athletics clubs providing the Pontic Greek youth with an opportunity to participate in organised sporting competition. The Hellenic Athletic Club, Pontus Merzifounta, founded in 1903 was one such example formed by students attending Anatolia College in Merzifon near Amasya. The college's forced closure in 1921 by the Turkish government resulted in the schools relocation to Greece in 1924, along with much of the Greek population of Asia Minor in the aftermath of genocide and a subsequent treaty that agreed upon a population exchange between Greece and Turkey. This resulted in the establishment of Pontic and Anatolian Greek sporting clubs in Greece, of whom football is the sport in which they are most commonly associated. Today a number of these clubs still compete; some at a professional and intercontinental level. Such as:


title: Pontic Greeks

text: Outside of Greece, due to the widespread Pontic Greek diaspora, association football clubs also exist. In Australia, the Pontian Eagles SC are a semi-professional team based in Adelaide, South Australia and in Munich, Germany, FC Pontos have an academy relationship with PAOK FC.


title: Pontic Greeks

text: Pontic Greeks have also contributed to sporting successes internationally, not limited to but mostly representing Greece, with several team members a part of sports triumphs in major international basketball (2006 FIBA World Championship, Eurobasket 2005) and football tournaments (UEFA Euro 2004). Champion individuals of Pontic Greek origin have also emerged in World Championship and Olympic levels of competition for athletics (Katerina Stefanidi, Voula Patoulidou), gymnastics (Ioannis Melissanidis), diving (Nikolaos Siranidis), taekwondo (Alexandros Nikolaidis) and kick-boxing (Mike Zambidis, Stan Longinidis).


title: Pontic Greeks

text: On 19 May of each year, the Evzonoi of the Greek Army Presidential Guard ceremonial unit wear the traditional black Pontic uniform to commemorate the Pontic genocide.


title: Vitamin D deficiency

text: Vitamin D deficiency or hypovitaminosis D is a vitamin D level that is below normal. It most commonly occurs in people when they have inadequate exposure to sunlight, particularly sunlight with adequate ultraviolet B rays (UVB). Vitamin D deficiency can also be caused by inadequate nutritional intake of vitamin D; disorders that limit vitamin D absorption; and disorders that impair the conversion of vitamin D to active metabolites, including certain liver, kidney, and hereditary disorders. Deficiency impairs bone mineralization, leading to bone-softening diseases, such as rickets in children. It can also worsen osteomalacia and osteoporosis in adults, increasing the risk of bone fractures. Muscle weakness is also a common symptom of vitamin D deficiency, further increasing the risk of fall and bone fractures in adults. Vitamin D deficiency is associated with the development of schizophrenia.


title: Vitamin D deficiency

text: Vitamin D can be synthesized in the skin under the exposure of UVB from sunlight. Oily fish, such as salmon, herring, and mackerel, are also sources of vitamin D, as are mushrooms. Milk is often fortified with vitamin D; sometimes bread, juices, and other dairy products are fortified with vitamin D. Many multivitamins contain vitamin D in different amounts.


title: Vitamin D deficiency

text: Vitamin D deficiency is typically diagnosed by measuring the concentration of the 25-hydroxyvitamin D in the blood, which is the most accurate measure of stores of vitamin D in the body. One nanogram per millilitre (1 ng/mL) is equivalent to 2.5 nanomoles per litre (2.5 nmol/L).


title: Vitamin D deficiency

text: Vitamin D levels falling within this normal range prevent clinical manifestations of vitamin D insufficiency as well as vitamin D toxicity.


title: Vitamin D deficiency

text: In most cases, vitamin D deficiency is almost asymptomatic. It may only be detected on blood tests but is the cause of some bone diseases and is associated with other conditions:


title: Vitamin D deficiency

text: Those most likely to be affected by vitamin D deficiency are people with little exposure to sunlight. Certain climates, dress habits, the avoidance of sun exposure and the use of too much sunscreen protection can all limit the production of vitamin D.


title: Vitamin D deficiency

text: Elderly people have a higher risk of having a vitamin D deficiency due to a combination of several risk factors, including decreased sunlight exposure, decreased intake of vitamin D in the diet, and decreased skin thickness, which leads to further decreased absorption of vitamin D from sunlight.


title: Vitamin D deficiency

text: Since vitamin D (cholecalciferol) and vitamin D (ergocalciferol) are fat-soluble, humans and other animals with a skeleton need to store some fat. Without fat, the animal will have a hard time absorbing vitamin D and vitamin D, and the lower the fat percentage, the greater the risk of vitamin deficiency, which is true in some athletes who strive to get as lean as possible.


title: Vitamin D deficiency

text: Although rickets and osteomalacia are now rare in Britain, osteomalacia outbreaks in some immigrant communities included women with seemingly adequate daylight outdoor exposure wearing typical Western clothing. Having darker skin and reduced exposure to sunshine did not produce rickets unless the diet deviated from a Western omnivore pattern characterized by high intakes of meat, fish, and eggs and low intakes of high-extraction cereals. In sunny countries where rickets occurs among older toddlers and children, the rickets has been attributed to low dietary calcium intakes. This is characteristic of cereal-based diets with limited access to dairy products. Rickets was formerly a major public health problem among the US population; in Denver, almost two-thirds of 500 children had mild rickets in the late 1920s. An increase in the proportion of animal protein in the 20th-century American diet coupled with increased consumption of milk fortified with relatively small quantities of vitamin D coincided with a dramatic decline in the number of rickets cases. One study of children in a hospital in Uganda, however, showed no significant difference in vitamin D levels of malnourished children compared to non-malnourished children. Because both groups were at risk due to darker skin pigmentation, both groups had vitamin D deficiency. Nutritional status did not appear to play a role in this study.


title: Vitamin D deficiency

text: There is an increased risk of vitamin D deficiency in people who are considered overweight or obese based on their body mass index (BMI) measurement. The relationship between these conditions is not well understood. There are different factors that could contribute to this relationship, particularly diet and sunlight exposure. Alternatively, vitamin D is fat-soluble, so excess amounts can be stored in fat tissue and used during winter, when sun exposure is limited.


title: Vitamin D deficiency

text: The use of sunscreen with a sun protection factor of 8 can theoretically inhibit more than 95% of vitamin D production in the skin. In practice, however, sunscreen is applied so as to have a negligible effect on vitamin D status. The vitamin D status of those in Australia and New Zealand is unlikely to have been affected by campaigns advocating sunscreen. Instead, wearing clothing is more effective at reducing the amount of skin exposed to UVB and reducing natural vitamin D synthesis. Clothing that covers a large portion of the skin, when worn on a consistent and regular basis, such as the burqa, is correlated with lower vitamin D levels and an increased prevalence of vitamin D deficiency.


title: Vitamin D deficiency

text: Regions far from the equator have a high seasonal variation of the amount and intensity of sunlight. In the UK, the prevalence of low vitamin D status in children and adolescents is found to be higher in winter than in summer. Lifestyle factors such as indoor versus outdoor work and time spent in outdoor recreation play an important role.


title: Vitamin D deficiency

text: Additionally, vitamin D deficiency has been associated with urbanisation in terms of both air pollution, which blocks UV light, and an increase in the number of people working indoors. The elderly are generally exposed to less UV light due to hospitalisation, immobility, institutionalisation, and being housebound, leading to decreased levels of vitamin D.


title: Vitamin D deficiency

text: Because of melanin which enables natural sun protection, dark-skinned people are susceptible to vitamin D deficiency. Three to five times greater sun exposure is necessary for naturally darker skinned people to produce the same amount of vitamin D as those with white skin.


title: Vitamin D deficiency

text: Rates of vitamin D deficiency are higher among people with untreated celiac disease, inflammatory bowel disease, exocrine pancreatic insufficiency from cystic fibrosis, and short bowel syndrome, which can all produce problems of malabsorption. Vitamin D deficiency is also more common after surgical procedures that reduce absorption from the intestine, including weight loss procedures.


title: Vitamin D deficiency

text: Vitamin D deficiency is associated with increased mortality in critical illness. People who take vitamin D supplements before being admitted for intensive care are less likely to die than those who do not take vitamin D supplements. Additionally, vitamin D levels decline during stays in intensive care.


title: Vitamin D deficiency

text: Vitamin D (cholecalciferol) or calcitriol given orally may reduce the mortality rate without significant adverse effects.


title: Vitamin D deficiency

text: Infants who exclusively breastfeed need a vitamin D supplement, especially if they have dark skin or have minimal sun exposure. The American Academy of Pediatrics recommends that all breastfed infants receive 400 international units (IU) per day of oral vitamin D.


title: Vitamin D deficiency

text: Decreased exposure of the skin to sunlight is a common cause of vitamin D deficiency. People with a darker skin pigment with increased amounts of melanin may have decreased production of vitamin D. Melanin absorbs ultraviolet B radiation from the sun and reduces vitamin D production. Sunscreen can also reduce vitamin D production. Medications may speed up the metabolism of vitamin D, causing a deficiency.


title: Vitamin D deficiency

text: The liver is required to transform vitamin D into 25-hydroxyvitamin D. This is an inactive metabolite of vitamin D but is a necessary precursor (building block) to create the active form of vitamin D.


title: Vitamin D deficiency

text: The kidneys are responsible for converting 25-hydroxyvitamin D to 1,25-hydroxyvitamin D. This is the active form of vitamin D in the body. Kidney disease reduces 1,25-hydroxyvitamin D formation, leading to a deficiency of the effects of vitamin D.


title: Vitamin D deficiency

text: Intestinal conditions that result in malabsorption of nutrients may also contribute to vitamin D deficiency by decreasing the amount of vitamin D absorbed via diet. In addition, a vitamin D deficiency may lead to decreased absorption of calcium by the intestines, resulting in increased production of osteoclasts that may break down a person's bone matrix. In states of hypocalcemia, calcium will leave the bones and may give rise to secondary hyperparathyroidism, which is a response by the body to increase serum calcium levels. The body does this by increasing uptake of calcium by the kidneys and continuing to take calcium away from the bones. If prolonged, this may lead to osteoporosis in adults and rickets in children.


title: Vitamin D deficiency

text: The serum concentration of calcifediol, also called 25-hydroxyvitamin D (abbreviated 25(OH)D), is typically used to determine vitamin D status. Most vitamin D is converted to 25(OH)D in the serum, giving an accurate picture of vitamin D status. The level of serum 1,25(OH)D is not usually used to determine vitamin D status because it often is regulated by other hormones in the body such as parathyroid hormone. The levels of 1,25(OH)D can remain normal even when a person may be vitamin D deficient. Serum level of 25(OH)D is the laboratory test ordered to indicate whether or not a person has vitamin D deficiency or insufficiency. It is also considered reasonable to treat at-risk persons with vitamin D supplementation without checking the level of 25(OH)D in the serum, as vitamin D toxicity has only been rarely reported to occur.


title: Vitamin D deficiency

text: Levels of 25(OH)D that are consistently above 200 nanograms per milliliter (ng/mL) (or 500 nanomoles per liter, nmol/L) are potentially toxic. Vitamin D toxicity usually results from taking supplements in excess. Hypercalcemia is often the cause of symptoms, and levels of 25(OH)D above 150 ng/mL (375 nmol/L) are usually found, although in some cases 25(OH)D levels may appear to be normal. Periodic measurement of serum calcium in individuals receiving large doses of vitamin D is recommended.


title: Vitamin D deficiency

text: The official recommendation from the United States Preventive Services Task Force is that for persons that do not fall within an at-risk population and are asymptomatic, there is not enough evidence to prove that there is any benefit in screening for vitamin D deficiency.


title: Vitamin D deficiency

text: Vitamin-D overdose is impossible from UV exposure: the skin reaches an equilibrium where the vitamin degrades as fast as it is created.


title: Vitamin D deficiency

text: Exposure to photons (light) at specific wavelengths of narrowband UVB enables the body to produce vitamin D to treat vitamin D deficiency.


title: Vitamin D deficiency

text: In the United States and Canada as of 2016, the amount of vitamin D recommended is 400 IU per day for children, 600 IU per day for adults, and 800 IU per day for people over age 70. The Canadian Paediatric Society recommends that pregnant or breastfeeding women consider taking 2000 IU/day, that all babies who are exclusively breastfed receive a supplement of 400 IU/day, and that babies living north of 55°N get 800 IU/day from October to April.


title: Vitamin D deficiency

text: Treating vitamin D deficiency depends on the severity of the deficit. Treatment involves an initial high-dosage treatment phase until the required serum levels are reached, followed by the maintenance of the acquired levels. The lower the 25(OH)D serum concentration is before treatment, the higher is the dosage that is needed in order to quickly reach an acceptable serum level.


title: Vitamin D deficiency

text: The initial high-dosage treatment can be given on a daily or weekly basis or can be given in form of one or several single doses (also known as "stoss therapy", from the German word "Stoß", meaning "push").


title: Vitamin D deficiency

text: Therapy prescriptions vary, and there is no consensus yet on how best to arrive at an optimum serum level. While there is evidence that vitamin D raises 25(OH)D blood levels more effectively than vitamin D, other evidence indicates that D and D are equal for maintaining 25(OH)D status.


title: Vitamin D deficiency

text: For treating rickets, the American Academy of Pediatrics (AAP) has recommended that pediatric patients receive an initial two to three months of treatment with "high-dose" vitamin D therapy. In this regime, the daily dose of cholecalciferol is 1,000 IU for newborns, 1,000 to 5,000 IU for 1- to 12-month-old infants, and 5,000 IU for patients over 1 year of age.


title: Vitamin D deficiency

text: For adults, other dosages have been called for. A review of 2008/2009 recommended dosages of 1,000 IU cholecalciferol per 10 ng/mL required serum increase, to be given daily over two to three months. In another proposed cholecalciferol loading dose guideline for vitamin D-deficient adults, a weekly dosage is given, up to a total amount that is proportional to the required serum increase (up to the level of 75 nmL/L) and within certain body weight limits, to body weight.


title: Vitamin D deficiency

text: According to new data and practices relevant to vitamin D levels in the general population in France, to establish optimal vitamin D status and frequency of intermittent supplement dosing, patients with or at high risk for osteoporosis and vitamin D deficiency should start supplementation with a loading phase consisting of 50,000 IU weekly of vitamin D for 8 weeks in patients with levels <20 ng/mL and 50,000 IU weekly for 4 weeks in patients with levels between 20 and 30 ng/mL. Subsequently, long-term supplementation should be prescribed as 50,000 IU monthly. Should pharmaceutical forms suitable for daily supplementation become available, patients displaying good treatment adherence could take a daily dose determined based on the 25(OH)D level.


title: Vitamin D deficiency

text: Until now, there are no consistent data suggesting the ideal regimen of supplementation with vitamin D, and the question of the ideal time between doses is still of debate. Ish-Shalom et al. performed a study in elderly women to compare the efficacy and safety of a daily dose of 1,500 IU to a weekly dose of 10,500 IU and to a dose of 45,000 IU given every 28 days for two months. They concluded that supplementation with vitamin D can be equally achieved with daily, weekly, or monthly dosing frequencies.


title: Vitamin D deficiency

text: Another study comparing daily, weekly, and monthly supplementation of vitamin D in deficient patients was published by Takacs et al. They reported equal efficacy of 1,000 IU taken daily, 7,000 IU taken weekly, and 30,000 IU taken monthly. Nevertheless, these consistent findings differ from the report by Chel et al., in which a daily dose was more effective than a monthly dose. In that study, the compliance calculation could be questionable since only random samples of the returned medications were counted. In a study by De Niet et al., 60 subjects with vitamin D deficiency were randomized to receive 2,000 IU vitamin D3 daily or 50,000 IU monthly. They reported a similar efficacy of the two dosing frequencies, with the monthly dose providing more rapid normalization of vitamin D levels.


title: Vitamin D deficiency

text: Alternatively, a single-dose therapy is used for instance if there are concerns regarding the patient's compliance. The single-dose therapy can be given as an injection but is normally given in form of oral medication.


title: Vitamin D deficiency

text: The presence of a meal and the fat content of that meal may also be important. Because vitamin D is fat-soluble, it is hypothesized that absorption would be improved if patients are instructed to take their supplement with a meal. Raimundo et al. performed different studies confirming that a high-fat meal increased the absorption of vitamin D3 as measured by serum 25(OH) D. A clinical report indicated that serum 25(OH) D levels increased by an average of 57% over a 2-month to 3-month period in 17 clinic patients after they were instructed to take their usual dose of vitamin D with the largest meal of the day.


title: Vitamin D deficiency

text: Another study conducted in 152 healthy men and women concluded that diets rich in monounsaturated fatty acids may improve and those rich in polyunsaturated fatty acids may reduce the effectiveness of vitamin D3 supplements. In another study performed by Cavalier E. et al., 88 subjects received orally a single dose of 50,000 IU of vitamin D3 solubilized in an oily solution as two ampoules each containing 25,000 IU (D‐CURE®, Laboratories SMB SA, Brussels, Belgium) with or without a standardized high‐fat breakfast. No significant difference between fasting vs. fed conditions was observed.


title: Vitamin D deficiency

text: Once the desired serum level has been achieved, be it by a high daily or weekly or monthly dose or by a single-dose therapy, the AAP recommendation calls for a maintenance supplementation of 400 IU for all age groups, with this dosage being doubled for premature infants, dark-skinned infants and children, children who reside in areas of limited sun exposure (>37.5° latitude), obese patients, and those on certain medications.


title: Vitamin D deficiency

text: To maintain blood levels of calcium, therapeutic vitamin D doses are sometimes administered (up to 100,000 IU or 2.5 mg daily) to patients who have had their parathyroid glands removed (most commonly kidney dialysis patients who have had tertiary hyperparathyroidism, but also to patients with primary hyperparathyroidism) or with hypoparathyroidism. Patients with chronic liver disease or intestinal malabsorption disorders may also require larger doses of vitamin D (up to 40,000 IU or 1 mg (1000 micrograms) daily).


title: Vitamin D deficiency

text: The combination of vitamin D and vitamin K supplements has been shown in trials to improve bone quality. As high intake of vitamin D is a cause of raised calcium levels (hypercalcemia), the addition of vitamin K may be beneficial in helping to prevent vascular calcification, particularly in people with chronic kidney disease.


title: Vitamin D deficiency

text: Not all D3 deficiencies can be effectively supplemented or treated with vitamin D3 on its own. Older people or those who have fatty liver or metabolic syndrome have a reduced ability to absorb vitamin D3. In addition, in overweight or obese persons, excessive adipose tissue can sequester D3 from the circulation and reduce its access to other tissues. With age or in obesity, metabolic activation of D3 may be reduced by liver steatosis or by microbiome imbalance. Since Vitamin D is fat-soluble, it's advised to be taken with a meal high in fat since it significantly increase its uptake in healthy individuals.


title: Vitamin D deficiency

text: For vitamin D3 to perform its hormonal roles, it is converted into its biologically active metabolite, calcifediol, also known as "25-hydroxyvitamin D3", an activation occurring by a hydroxylation reaction in the liver via the cytochrome P450 system, and in the gut microbiome.


title: Vitamin D deficiency

text: The estimated percentage of the population with a vitamin D deficiency varies based on the threshold used to define a deficiency.


title: Vitamin D deficiency

text: Recommendations for 25(OH)D serum levels vary across authorities, and probably vary based on factors like age; calculations for the epidemiology of vitamin D deficiency depend on the recommended level used.


title: Vitamin D deficiency

text: A 2011 Institute of Medicine (IOM) report set the sufficiency level at 20 ng/mL (50 nmol/L), while in the same year The Endocrine Society defined sufficient serum levels at 30 ng/mL and others have set the level as high as 60 ng/mL. As of 2011 most reference labs used the 30 ng/mL standard.


title: Vitamin D deficiency

text: Applying the IOM standard to NHANES data on serum levels, for the period from 1988 to 1994 22% of the US population was deficient, and 36% were deficient for the period between 2001 and 2004; applying the Endocrine Society standard, 55% of the US population was deficient between 1988 and 1994, and 77% were deficient for the period between 2001 and 2004.


title: Vitamin D deficiency

text: In 2011 the Centers for Disease Control and Prevention applied the IOM standard to NHANES data on serum levels collected between 2001 and 2006, and determined that 32% of Americans were deficient during that period (8% at risk of deficiency, and 24% at risk of inadequacy).


title: Vitamin D deficiency

text: The role of diet in the development of rickets was determined by Edward Mellanby between 1918 and 1920. In 1921, Elmer McCollum identified an antirachitic substance found in certain fats that could prevent rickets. Because the newly discovered substance was the fourth vitamin identified, it was called vitamin D. The 1928 Nobel Prize in Chemistry was awarded to Adolf Windaus, who discovered the steroid 7-dehydrocholesterol, the precursor of vitamin D.


title: Vitamin D deficiency

text: Prior to the fortification of milk products with vitamin D, rickets was a major public health problem. In the United States, milk has been fortified with 10 micrograms (400 IU) of vitamin D per quart since the 1930s, leading to a dramatic decline in the number of rickets cases.


title: Vitamin D deficiency

text: Some evidence suggests vitamin D deficiency may be associated with a worse outcome for some cancers, but evidence is insufficient to recommend that vitamin D be prescribed for people with cancer. Taking vitamin D supplements has no significant effect on cancer risk. Vitamin D, however, appears to decrease the risk of death from cancer but concerns with the quality of the data exist.


title: Vitamin D deficiency

text: Vitamin D deficiency is thought to play a role in the pathogenesis of non-alcoholic fatty liver disease.


title: Vitamin D deficiency

text: Evidence suggests that vitamin D deficiency may be associated with impaired immune function. Those with vitamin D deficiency may have trouble fighting off certain types of infections. It has also been thought to correlate with cardiovascular disease, type 1 diabetes, type 2 diabetes, and some cancers.


title: Police Squad!

text: Police Squad! is an American television crime comedy series that was broadcast on the ABC network in 1982. It was created by David Zucker, Jim Abrahams, and Jerry Zucker, starring Leslie Nielsen as Frank Drebin. A spoof of police procedurals and many other television shows and movies, the series features Zucker, Abrahams, and Zucker's usual sight gags, wordplay, and non sequiturs. It resembles the Lee Marvin police show "M Squad" (in particular the opening credits) and the late 1960s series "Felony Squad". It was canceled after six episodes, and yielded "The Naked Gun" film series from 1988 to 1994.


title: Police Squad!

text: "Police Squad!" was created by David Zucker, Jim Abrahams, and Jerry Zucker, who had previously worked on "The Kentucky Fried Movie" (1977) and "Airplane!" (1980). They declined to work on a sequel to "Airplane!" and instead chose to apply the comedic approach of that film to television.


title: Police Squad!

text: The producers were contracted to produce an initial six episodes. The show aired as a mid-season replacement in March 1982, but was taken off the schedule after four episodes. The remaining two episodes were dumped onto the summer schedule in place of the usual summer reruns. Against critical acclaim, the show was canceled by ABC after just six episodes. The show gained a strong cult following through repeat broadcasts on cable channels.


title: Police Squad!

text: Alan North played Captain Ed Hocken, and Peter Lupus co-starred as Officer Norberg. In the films, those roles were played by George Kennedy and O. J. Simpson respectively, with Norberg renamed Nordberg. The only actors who reprised their roles in the films are Leslie Nielsen, Ed Williams as scientist Ted Olson, and Ronald "Tiny Ron" Taylor as the very tall Al. Joyce Brothers played herself in the fourth episode and in "". Robert Goulet, one of the "special guest stars" killed during the title sequence, plays the villain Quentin Hapsburg in "".


title: Police Squad!

text: Each episode's voiced title differs from that displayed on screen. In the following list, the voiced title is in parentheses.


title: Police Squad!

text: Leslie Nielsen portrayed Sergeant Frank Drebin, detective lieutenant of Police Squad. Jerry Zucker explained that the name Drebin was picked blindly from the phone book. Zucker, Abrahams, and Zucker had met Nielsen when working on "Airplane!" (1980) and decided that their kind of humor matched. The team said that Nielsen would be perfect as Drebin, as the character lampooned the roles that Nielsen had played in television dramas such as "" and "S.W.A.T.". Ed Williams, who co-starred as lab technician Ted Olson, had been a science teacher for many years and had some previous acting experience. Zucker, Abrahams, and Zucker were amazed by his performance.


title: Police Squad!

text: Rex Hamilton is credited in every episode as "Abraham Lincoln", with the same clip in all opening credits as his only appearance.


title: Police Squad!

text: Nielsen, Taylor, and Williams were the only members of the main cast who reprise their characters into "The Naked Gun" film series. Captain Ed Hocken was portrayed by George Kennedy in the film series, and O. J. Simpson played Officer Nordberg (slightly renamed from "Norberg").


title: Police Squad!

text: The show's opening sequence is a satire on traditional crime-drama opening sequences, particularly those of "M Squad" and various Quinn Martin shows such as "The Fugitive" and particularly "The New Breed" (which also stars Nielsen). Hank Simms, who had worked as an announcer for some of Martin's programs, announced the title of each episode, though the spoken title never matches the title caption. The sequence introduces Nielsen and North during a shootout, and Abraham Lincoln impersonator Rex Hamilton, who dramatically returns gunfire to John Wilkes Booth, as his only appearance.


title: Police Squad!

text: Another recurring gag in the opening credits sequence is the "special guest star", a celebrity who is introduced but immediately murdered. These special guest stars are Lorne Greene, Georg Stanford Brown, Robert Goulet, William Shatner, Florence Henderson, and William Conrad. A scene with John Belushi, tied to blocks of concrete under water, was filmed but replaced with footage of Henderson following Belushi's death before the episode was broadcast. Belushi's death shocked Zucker, Abrahams, and Zucker, as they had joked about it after he had almost choked during the filming of the scene. A list of possible celebrity death shots is in the DVD release of 2006.


title: Police Squad!

text: The show was intended to mock police dramas in the same way in which "Airplane!" mocks disaster movies. Zucker, Abrahams, and Zucker wrote the pilot episode, in which most straight lines were directly copied from an "M Squad" episode. The pilot episode is a remake of almost each scene of "More Deadly", the opening episode of the second season of "M Squad". Pat Proft, who had worked with Zucker, Abrahams, and Zucker on "The Kentucky Fried Movie" (1977) and "Airplane!" (1980), wrote the third episode. Robert Wuhl was invited to join the writing staff after he had auditioned for the lead role in "Airplane!". He co-wrote the show's second and sixth episodes with Tino Insana. Both episodes contain cultural references to old movies such as "On the Waterfront" and "The French Connection". In Wuhl's audio commentary for the DVD, he mentioned that it was a nice opportunity, but that he did not really feel a connection with the show, especially because of its short run.


title: Police Squad!

text: ABC announced the cancellation of "Police Squad!" after four of its six episodes had aired in March 1982. The final two episodes were aired that summer. In an interview for the DVD release of the series, Nielsen said ABC entertainment president Tony Thomopoulos asserted "Police Squad!" was canceled because viewers had to pay close attention to the show in order to get much of the humor: "the viewer had to watch it in order to appreciate it". Nielsen also thought the premise was more effective in the successful "Naked Gun" films because the much larger screen size in a cinema increases the visual gags. In its annual "Cheers and Jeers" issue, "TV Guide" magazine called the explanation for the cancellation "the most stupid reason a network ever gave for ending a series".


title: Police Squad!

text: In 1985, Paramount Home Video first released all six episodes of the show on VHS, Betamax, and LaserDisc formats as two separate volumes: "Police Squad!: Help Wanted!" and "More! Police Squad!", each with three episodes in their production order.


title: Police Squad!

text: Paramount and CBS DVD first released the series on DVD in 2006 in a keep case on one disc. The episodes are in airing order from ABC. The DVD extras include production notes from network executives, a "freeze-frame" that was filmed but never used, bloopers, casting tests, and an interview with Nielsen. Zucker, Abrahams, and Zucker, producer Robert K. Weiss, and writer Robert Wuhl recorded audio commentary for the first, third, and sixth episodes. Critics universally praised how the show was still funny after more than 20 years.


title: Police Squad!

text: Six years after the cancellation of "Police Squad!", the first "Naked Gun" film was released, titled "". It performed well at the box office, grossing around $78,756,177. It became so popular that two sequels, "" (1991) and "" (1994), were released. "The Naked Gun : The Smell of Fear" was considered the most successful of the three, grossing around $86,930,411, and "Naked Gun : The Final Insult" grossed $51,132,598. Roger Ebert rated the first movie out of four stars and gave three stars to each of the two following films.


title: Police Squad!

text: A series of British advertisements for Red Rock Cider were made in the same style, with the opening titles changed to other names such as "Fraud Squad" or "Fried Squid", and featuring Leslie Nielsen. The advertisements were shown in British cinemas as well as on television. They were directed by John Lloyd, with such apparent success that Zucker, Abrahams, and Zucker approached him to direct "Naked Gun : The Final Insult", but he turned them down.


title: Police Squad!

text: During the WWE's Summerslam 1994 pay-per-view event, the "Police Squad!" characters look for The Undertaker, who had previously vanished.


title: Police Squad!

text: On Rotten Tomatoes, Police Squad! has an aggregate score of 90% based on 28 positive and three negative critic reviews. The website’s consensus reads: "Wacky, inventive, and endlessly quotable, "Police Squad!" is a hysterically funny leap forward for TV comedy that was tragically ahead of its time."


title: Police Squad!

text: Upon the home video release in 1985, "Washington Post" critic Tom Shales commented "People can rent them and laugh, and then cry that ABC was so cruel." In 2009, the DVD set was nominated for a Satellite Award for Best DVD Release of a TV Show, though it lost to the DVD set of the eighth season of Fox's "The Simpsons". In 2013, "TV Guide" ranked it #7 on its list of 60 shows that were "Cancelled Too Soon".


title: Police Squad!

text: Matt Groening, creator of "The Simpsons", has said, "If "Police Squad!" had been made twenty years later, it would have been a smash. It was before its time. In 1982 your average viewer was unable to cope with its pace, its quick-fire jokes. But these days they'd have no problems keeping up, I think we've proved that."


title: Dressage

text: Dressage ( or ; a French term, most commonly translated to mean "training") is a form of horse riding performed in exhibition and competition, as well as an art sometimes pursued solely for the sake of mastery. As an equestrian sport defined by the International Equestrian Federation, dressage is described as "the highest expression of horse training" where "horse and rider are expected to perform from memory a series of predetermined movements."


title: Dressage

text: Competitions are held at all levels from amateur to the Olympic Games and World Equestrian Games. Its fundamental purpose is to develop, through standardized progressive training methods, a horse's natural athletic ability and willingness to perform, thereby maximizing its potential as a riding horse. At the peak of a dressage horse's gymnastic development, the horse responds smoothly to a skilled rider's minimal aids. The rider is relaxed and appears effort-free while the horse willingly performs the requested movement.


title: Dressage

text: The discipline has a rich history with ancient roots in the writings of Xenophon. Modern dressage has evolved as an important equestrian pursuit since the Renaissance when Federico Grisone's "The Rules of Riding" was published in 1550, the first treatise on equitation in over a thousand years since Xenophon's "On Horsemanship". Much about training systems used today reflects practices of classical dressage.


title: Dressage

text: In modern dressage competition, successful training at the various levels is demonstrated through the performance of "tests", prescribed series of movements ridden within a standard arena. Judges evaluate each movement on the basis of a standard appropriate to the level of the test and assign each movement a score from zero to ten – zero being "not executed" and 10 being "excellent". A score of 9 is very good and is a high mark, while a competitor achieving all 6s (or 60% overall) should consider moving on to the next level.


title: Dressage

text: The most popular horse breeds seen at the Olympics and other international FEI competitions are warmblood horses bred for dressage.


title: Dressage

text: In classical dressage training and performances that involve the "airs above the ground" ("described below"), the "baroque" breeds of horses are popular and purposely bred for these specialties.


title: Dressage

text: There are two sizes of arenas, small and standard. Each has letters assigned to positions around the arena for dressage tests to specify where movements are to be performed. Cones with letters on them are positioned on the sidelines of the arena for reference as to where a movement is to be performed.


title: Dressage

text: The small arena is and is used for the lower levels of eventing in the dressage phase, as well as for some pure dressage competitions at lower levels. Its letters around the outside edge, starting from the point of entry and moving clockwise, are A-K-E-H-C-M-B-F. Letters also mark locations along the "center line" in the middle of the arena. Moving down the center line from A, they are D-X-G, with X being directly between E and B.


title: Dressage

text: The standard arena is , and is used for tests in both pure dressage and eventing. The standard dressage arena letters are A-K-V-E-S-H-C-M-R-B-P-F. The letters on the long sides of the arena, nearest the corners, are in from the corners, and are apart from each other. The letters along the center line are D-L-X-I-G, with X again being halfway down the arena. There is speculation as to why these letters were chosen. Most commonly it is believed because the German cavalry had a 20 × 60-metre area in-between the barracks which had the letters posted above the doors.


title: Dressage

text: In addition to the center line, the arena also has two "quarter lines", which lie between the center line and the long side of the arena. However, these are infrequently, if ever, used for competition except in a freestyle.


title: Dressage

text: At the start of the test, the horse enters the arena at an opening at A. Ideally this opening is then closed for the duration of the test. However, this is not always logistically possible, particularly at smaller competitions with few volunteers.


title: Dressage

text: Judges are registered through their national federation depending on the judge's experience and training, with the highest qualified being registered with the FEI for international competition. Judges are strictly regulated to ensure as consistent marking as possible within the limits of subjectivity, and in FEI competitions, it is expected that all judges' final percentage be within five percent of each other.


title: Dressage

text: There is always a judge sitting at C, although for upper-level competition there can be up to seven judges at different places around the arena — at C, E, B, K, F, M, and H — which allows the horse to be seen in each movement from all angles. This helps prevent certain faults from going unnoticed, which may be difficult for a judge to see from only one area of the arena. For example, the horse's straightness going across the diagonal may be assessed by judges at M and H.


title: Dressage

text: Although the judge's positions are known by their closest letter, only C, B, & E are actually directly behind their respective marker, with the other judges being on the short sides (on a plane with C, and two metres in from the edge of the arena for M & H, and at the A end of the arena and five metres in from the long side of the arena for F & K) rather than on the long side where the letter would seem to indicate.


title: Dressage

text: Dressage competitions consist of a series of individual tests with an increasing level of difficulty. The most accomplished horse and rider teams perform FEI tests, written by the international equestrian governing body called the Fédération Équestre Internationale or FEI. The highest level of modern competition is at the Grand Prix level. This is the level test ridden in the prestigious international competitions (CDIs), such as the Olympic games, Dressage World Cup, and World Equestrian Games. Dressage governed by the rules of the FEI include the following levels: "small tour" (Prix St. Georges and Intermediate I) Intermediate A, Intermediate B and "big tour" (Intermediate II, Grand Prix and Grand Prix Special).


title: Dressage

text: In addition, there are four to six lower levels, occasionally more, regulated in individual nations by their respective national federation (such as the USDF in America, British Dressage, Dressage Australia etc.). The lower levels ask horses for basic gaits, relatively large circles, and a lower level of collection than the international levels. Lateral movements are not required in the earliest levels, and movements such as the leg yield, shoulder-in, or haunches-in are gradually introduced as the horse progresses, until the point at which the horse can compete in the FEI levels.


title: Dressage

text: Apart from competition, there is the tradition of classical dressage, in which the traditional training of dressage is pursued as an art form. The traditions of the masters who originated Dressage are kept alive by the Spanish Riding School in Vienna, Austria, Escola Portuguesa de Arte Equestre in Lisbon, Portugal, and the "Cadre Noir" in Saumur, France. This type of schooling is also a part of Portuguese and Spanish bullfighting exhibitions.


title: Dressage

text: Dressage tests are the formalized sequence of a number of dressage movements used in competition. Although horses and riders are competing against each other, tests are completed by one horse and rider combination at a time, and horses and riders are judged against a common standard, rather than having their performance scored relative to the other competitors.


title: Dressage

text: At the upper levels, tests for international competitions, including the Olympics, are issued under the auspices of the FEI. At the lower levels, and as part of dressage training each country authorizes its own set of tests. For example, in the US it is the United States Equestrian Federation and the United States Dressage Federation. In Great Britain, dressage is overseen by British Dressage. Pony Clubs also produce their own tests, including basic walk/trot tests which cater for child riders.


title: Dressage

text: Each test is segmented into a number of sequential blocks which may contain one or more movements. Each block is generally scored between zero and ten on a scale such as the following:


title: Dressage

text: Since 2011, all international tests, and some national tests have also allowed half marks (0.5 – 9.5) in all blocks.


title: Dressage

text: Along with each mark a "comment" may be given, which can describe things a rider and horse lack during the movement, or what they have. Any of the definitions of each numeric mark can only be used in the comment if the mark corresponds with the definition.


title: Dressage

text: In addition to marks for the dressage movements, marks are also awarded for more general attributes such as the horse's gaits, submission, impulsion and the rider's performance. Some segments are given increased weight by the use of a multiplier, or coefficient. Coefficients are typically given a value of 2, which then doubles the marks given for that segment. Movements that are given a coefficient are generally considered to be particularly important to the horse's progression in training, and should be competently executed prior to moving up to the next level of competition. The scores for the general attributes of gait, submission, impulsion, and rider performance mentioned above are scored using a coefficient.


title: Dressage

text: Scribing (also known as pencilling or writing) is the writing down of the scores and comments of judges at dressage events so that the judge can concentrate on the performance. In addition to this, the scribe should check the identity of each competitor, and ensure that the test papers are complete and signed before handing them to the scorers. The scribe should have some knowledge of dressage terminology, be smartly dressed and have legible handwriting. The scribe should also be professional in manner, neutral and not engage in small talk or make comments. It is permissible to use abbreviations provided they are accepted and intelligible.


title: Dressage

text: According to the United States Dressage Federation, "Anyone can volunteer at a schooling show to scribe. Schooling shows are not recognized as official shows but are a great way to practice riding tests or to learn to scribe for a judge. Once you have scribed at a schooling show and at the lower levels, you may ask to scribe at a recognized show and perhaps even the FEI levels of competition." Scribing or pencilling is also an integral part of a judge's training as they look to become accredited or upgrade to a higher level.


title: Dressage

text: At the international level, dressage tests governed by the FEI are the Prix St. Georges, Intermediare I, Intermediare II, and Grand Prix. The dressage tests performed at the Olympic Games dressage competition are Grand Prix. This level of test demands the most skill and concentration from both horse and rider.


title: Dressage

text: Tests ridden at the Olympic Games are scored by a panel of seven international judges. Each movement in each test receives a numeric score from 0 (lowest) to 10 (highest) and the resulting final score is then converted into a percentage, which is carried out to three decimal points. The higher the percentage, the higher the score. However, in eventing dressage the score is calculated by dividing the number of points achieved by the total possible points, then multiplied by 100 (rounded to 2 decimal points) and subtracted from 100. Thus, a lower score is better than a higher score.


title: Dressage

text: Olympic team medals are won by the teams with the highest combined percentages from their best three rides in the Grand Prix test.


title: Dressage

text: Once the team medals are determined, horses and riders compete for individual medals. The team competition serves as the first individual qualifier, in that the top 25 horse/rider combinations from the Grand Prix test move on to the next round. The second individual qualifier is the Grand Prix Special test, which consists of Grand Prix movements arranged in a different pattern. For those 25 riders, the scores from the Grand Prix and the Grand Prix Special are then combined and the resulting top 15 horse/rider combinations move on to the individual medal competition—the crowd-pleasing Grand Prix Freestyle to Music (Kür).


title: Dressage

text: For their freestyles, riders and horses perform specially choreographed patterns to music. At this level, the freestyle tests may contain all the Grand Prix movements, as well as double canter pirouettes, pirouettes in piaffe, and half-pass in passage. For the freestyle, judges award technical marks for the various movements, as well as artistic marks. In the case of a tie, the ride with the higher artistic marks wins.


title: Dressage

text: Competitive dressage training in the U.S. is based on a progression of six steps developed by the German National Equestrian Foundation. This system is arranged in a pyramid or sequential fashion, with “rhythm and regularity” at the start of the pyramid and “collection” at the end. The training scale is helpful and effective as a guide for the training of any horse, but has come to be most closely associated with dressage. Despite its appearance, the training scale is not meant to be a rigid format. Instead, each level is built on as the horse progresses in training: so a Grand Prix horse would work on the refinement of the first levels of the pyramid, instead of focusing on only the final level: “collection.” The levels are also interconnected. For example, a crooked horse cannot develop impulsion, and a horse that is not relaxed will be less likely to travel with a rhythmic gait. However, this training scale as presented below is a translation from the German to the English.


title: Dressage

text: Rhythm, gait, tempo, and regularity should be the same on straight and bending lines, through lateral work, and through transitions. Rhythm refers to the sequence of the footfalls, which should only include the pure walk, pure trot, and pure canter. The regularity, or purity, of the gait includes the evenness and levelness of the stride. Once a rider can obtain pure gaits, or can avoid irregularity, the combination may be fit to do a more difficult exercise. Even in the very difficult piaffe there is still regularity: the horse "trots on the spot" in place, raising the front and hind legs in rhythm.


title: Dressage

text: The second level of the pyramid is relaxation (looseness). Signs of looseness in the horse may be seen by an even stride that is swinging through the back and causing the tail to swing like a pendulum, looseness at the poll, a soft chewing of the bit, and a relaxed blowing through the nose. The horse makes smooth transitions, is easy to position from side to side, and willingly reaches down into the contact as the reins are lengthened.


title: Dressage

text: Contact—the third level of the pyramid—is the result of the horse's pushing power, and should never be achieved by the pulling of the rider's hands. The rider encourages the horse to stretch into soft hands that allow the horse to lift the base of the neck, coming up into the bridle, and should always follow the natural motion of the animal's head. The horse should have equal contact in both reins.


title: Dressage

text: The pushing power (thrust) of the horse is called impulsion, and is the fourth level of the training pyramid. Impulsion is created by storing the energy of engagement (the forward reaching of the hind legs under the body).


title: Dressage

text: Impulsion can occur at the walk, trot and canter. It is highly important to establish good, forward movement and impulsion at the walk, as achieving desirable form in the trot and canter relies heavily on the transition from a good, supple, forward walk.


title: Dressage

text: Impulsion not only encourages correct muscle and joint use, but also engages the mind of the horse, focusing it on the rider and, particularly at the walk and trot, allowing for relaxation and dissipation of nervous energy.


title: Dressage

text: A horse is straight when the hind legs follow the path of the front legs, on both straight lines and on bending lines, and the body follows the line of travel. Straightness allows the horse to channel its impulsion directly toward its center of balance, and allows the rider's hand aids to have a connection to the hind end.


title: Dressage

text: When working on straightness in the horse, a common exercise is used called 'shoulder in'. The exercise is the beginning of straightness in the horse as well as collection and can increase impulsion in the horse.


title: Dressage

text: At the apex of the training scale stands collection. It may refer to collected gaits: they can be used occasionally to supplement less vigorous work. It involves difficult movements (such as flying changes) in more advanced horses. Collection requires greater muscular strength, so must be advanced upon slowly. When in a collected gait, the stride length should shorten, and the stride should increase in energy and activity.


title: Dressage

text: When a horse collects, more weight moves to the hindquarters. Collection is natural for horses and is often seen during pasture play. A collected horse can move more freely. The joints of the hind limbs have greater flexion, allowing the horse to lower the hindquarters, bringing the hind legs further under the body, and lighten and lift the forehand. In essence, collection is the horse's ability to move its centre of gravity to the rear while lifting the freespan of its back to better round under the rider.


title: Dressage

text: The "school jumps," or "airs above the ground," are a series of higher-level classical dressage movements where the horse leaves the ground. These include the capriole, courbette, the mezair, the croupade, and levade. None are used in modern competitive dressage, but are performed by horses of various riding academies, including the Spanish Riding School in Vienna, Escola Portuguesa de Arte Equestre in Lisbon, Portugal, and the Cadre Noir in Saumur. Baroque horse breeds such as the Andalusian, Lusitano and Lipizzan are most often trained to perform the "airs" today, in part due to their powerfully conformed hindquarters, which allow them the strength to perform these difficult movements.


title: Dressage

text: There is a popular belief that these moves were originally taught to horses for military purposes, and indeed both the Spanish Riding School and the Cadre Noir are military foundations. However, while agility was necessary on the battlefield, most of the airs as performed today would have actually exposed horses' vulnerable underbellies to the weapons of foot soldiers. It is therefore more likely that the airs were exercises to develop the agility, responsiveness and physiology of the military horse and rider, rather than to be employed in combat.


title: Dressage

text: The earliest practitioner who wrote treatises that survive today that describe sympathetic and systematic training of the horse was the Greek general Xenophon (427–355 BC). Despite living over 2000 years ago, his ideas are still widely praised. Beginning in the Renaissance a number of early modern trainers began to write on the topic of horse training, each expanding upon the work of their predecessors, including Federico Grisone (mid-16th century), Antoine de Pluvinel (1555–1620), William Cavendish, 1st Duke of Newcastle (1592–1676), François Robichon de La Guérinière (1688–1751), François Baucher (1796–1873), and Gustav Steinbrecht (1808–1885). The 20th century saw an increase in writing and teaching about Dressage training and techniques as the discipline became an international sport with the influence of Olympic Equestrian competition.


title: Dressage

text: The rules on permitted cavessons (nosebands) saddles, saddle pads, etc., are subject to change and do change as more and more styles and stylish equipments are introduced into the marketplace. Dressage horses are shown in minimal tack. They are not permitted to wear boots (including hoof or bell boots) or wraps (including tail bandages) during the test, nor are they allowed to wear martingales or training devices such as draw or running reins or the gogue anywhere on the showgrounds during the competition. Due to the formality of dressage, tack is usually black leather, although dark brown is seen from time to time.


title: Dressage

text: An English-style saddle is required for riding dressage, specifically a "dressage saddle" which is modeled exclusively for the discipline. It is designed with a long and straight saddle flap, mirroring the leg of the dressage rider, which is long with a slight bend in the knee, a deep seat and usually a pronounced knee block. Dressage saddles have longer billets and use shorter girth than other types of English saddles to minimize the straps and buckles underneath the rider's legs. The saddle is usually placed over a square, white saddle pad. Colored trim on the white saddle pad is permitted. A dressage saddle is required in FEI classes, although any simple English-type saddle may be used at the lower levels.


title: Dressage

text: At the lower levels of dressage, a bridle includes a plain cavesson, drop noseband, or flash noseband. Currently, drop nosebands are relatively uncommon, with the flash more common. At the upper levels a plain cavesson is used on a double bridle. Figure-eight (also called Grackle) nosebands are not allowed in pure dressage, however they are allowed in the dressage phase of eventing. Riders are not allowed to use Kineton nosebands, due to their severity. Beads and colored trim are permitted along the brow band of the bridle.


title: Dressage

text: The dressage horse at lower levels is only permitted to be shown at recognized competitions in a snaffle bit, though the detail regarding bitting varies slightly from organization to organization. The loose-ring snaffle with a single- or double-joint is most commonly seen. Harsher snaffle bits, such as twisted wire, corkscrews, slow-twists, and waterfords are not permitted, nor are pelhams, kimberwickes, or gag bits. Upper level and FEI dressage horses are shown in a double bridle, using both a bradoon and a curb bit with a smooth curb chain. Traditionally, the snaffle is used to open and lift the poll angle, while the curb is used to bring the nose of the horse towards the vertical.


title: Dressage

text: Dressage horses are turned out to a high standard. It is usual for horses to have their manes braided (also known as plaited). In eventing, the mane is preferred to be braided on the right; in competitive dressage, however, it is occasionally braided on the left, should it naturally fall there. Braids vary in size, but Europeans tend to put in fewer, larger braids, while Americans tend to have more smaller braids per horse. Braids are occasionally accented in white tape, which also helps them stay in throughout the day. The forelock may be left unbraided; this style is most common with stallions. Braids are held in place by either yarn or rubber bands. It is a common misconception that a dressage horse must be braided, however this is not the case, and some riders may choose for various reasons not to braid.


title: Dressage

text: Horses are not permitted to wear "visual enhancements" that might be considered distracting, or that might influence the judge's perception of the horse. Bangles, ribbons, or other decorations are not allowed in the horse's mane or tail. Competitors are not allowed to use black hoof polish on white hooves. Tail extensions are permitted in some countries, but not in FEI-sanctioned competitions.


title: Dressage

text: The tail is usually not braided (although it is permitted), because it may cause the horse to carry the tail stiffly. Because the tail is an extension of the animal's spine, a supple tail is desirable as it shows that the horse is supple through its back. The tail should be "banged", or cut straight across (usually above the fetlocks but below the hocks when held at the point where the horse naturally carries it). The dock is pulled or trimmed to shape it and give the horse a cleaner appearance.


title: Dressage

text: The bridle path is clipped or pulled, usually only 1–2 inches. The animal's coat may be trimmed. American stables almost always trim the muzzle, face, ears, and legs, while European stables do not have such a strict tradition and may leave different parts untrimmed.


title: Dressage

text: Clear hoof polish may be applied before the horse enters the arena. The horse is thoroughly clean. The horse's saliva often forms "foam" about the horse's lips, which is generally considered to be a sign of the horse's submission and acceptance of the bit. Some riders believe that foam should not be cleaned off the horse's mouth before entering the arena due to it being a sign of submission. Conversely, some riders choose to wipe the foam from their horses' mouths prior to entering the arena, as foam can land on the horses' chests and legs. The presence of foam does not necessarily indicate the horse's acceptance of the bit, as certain metals such as German silver may cause the horse's salivation to increase without full acceptance of the bit.


title: Dressage

text: Quarter marks are sometimes seen, especially in the dressage phase of eventing. However, they are currently considered somewhat old-fashioned.


title: Dressage

text: Dressage riders, like their horses, are dressed for formality. In competition, they wear white, cream or pale-coloured breeches, often full-seat leather to help them "stick" in the saddle, with a white shirt and stock tie with a small pin. Gloves are usually white, although less-experienced riders or those at the lower levels often opt for black, as white gloves tend to accentuate the movement of a less-experienced rider's unsteady hands. The coat worn is usually solid black with metal buttons, although solid navy is also seen. In upper-level classes, the riders wear a tailed jacket (shadbelly) with a yellow vest or vest points instead of a plain dressage coat.


title: Dressage

text: Riders usually wear tall dress boots, although field boots or paddock boots with half chaps may be worn by riders at the lower levels. Spurs are required at the upper levels, and riders must maintain a steady lower leg for proper use. A whip may be carried in any competition except in a CDI or a national championship, and the length is regulated. Whips are not permitted in eventing dressage when entering space around arena or during the test for FEI events. Whips (no longer than 120 cm) are permitted in eventing dressage at any time for USEA tests, except USEF/USEA Championships and USEA Championship divisions.


title: Dressage

text: If the dressage rider has long hair, it is typically worn in a bun with a hair net or show bow. A hair net blends in with the rider's hair color, whereas a show bow combines a barrette or hair tie with a small bow and thick hair net, and is usually black. Lower-level riders may use a derby, hunting cap, or ASTM/SEI-approved Equestrian helmet. In the United States, junior riders and riders through Fourth Level at recognized competitions are required to wear an ASTM/SEI approved helmet to protect against head trauma in the event of a fall. At the upper levels, a top hat that matches the rider's coat is traditionally worn, though use of helmets is legal and increasing in popularity.


title: Dressage

text: At FEI competitions, members of the military, police, national studs, national schools and national institutes retain the right to wear their service dress instead of the dress required of civilian riders.


title: Epidural administration

text: Epidural administration (from Ancient Greek ἐπί, , upon" + "dura mater") is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration involves the placement of a catheter into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by Spanish military surgeon Fidel Pagés. In the United States, over 50% of childbirths involve the use of epidural anesthesia.


title: Epidural administration

text: Epidural anaesthesia causes a loss of sensation, including pain, by blocking the transmission of signals through nerve fibres in or near the spinal cord. For this reason, epidurals are commonly used for pain control during childbirth and surgery. The technique is considered safe and effective for providing pain relief during childbirth and surgery, and is considered more effective and safer than giving pain medication by mouth or through an intravenous line. An epidural injection may also be used to administer steroids for the treatment of inflammatory conditions of the spinal cord. It is not recommended for people with severe bleeding disorders, low platelets, or infections near the intended injection site. Severe complications from epidural administration are rare, but can include problems resulting from improper administration, as well as side effects of the medicines administered. The most common complications of epidural injections include bleeding problems, headaches, and inadequate pain control. Epidural analgesia during childbirth may also impact the mother's ability to move during labor. Very large doses of anesthetics or analgesics may result in respiratory depression.


title: Epidural administration

text: An epidural injection may be administered at any point of the spine, but most commonly the lumbar spine, below the end of the spinal cord. The specific administration site determines the specific nerves affected, and thus the area of the body from which pain will be blocked. Insertion of an epidural catheter consists of threading a needle between bones and ligaments to reach the epidural space without going so far as to puncture the "dura mater". Saline or air may be used to confirm placement in the epidural space. Alternatively, direct imaging of the injection area may be performed with a portable ultrasound or fluoroscopy to confirm correct placement. Once placed, medication may be administered in one or more single doses, or may be continually infused over a period of time. When placed properly, an epidural catheter may remain inserted for several days, but is usually removed when the use of less invasive administration methods (such as taking medication by mouth) is a viable alternative.


title: Epidural administration

text: Epidural injections are commonly used to provide pain relief (analgesia) during childbirth. This usually involves epidural injection of a local anesthetic and opioids, commonly called an "epidural". This is more effective than oral or intra venal (IV) opioids and other common modalities of analgesia in childbirth. After an epidural is administered, a woman may not feel pain, but may still feel pressure. Epidural clonidine is rarely used but has been extensively studied for management of analgesia during labor.


title: Epidural administration

text: Epidural analgesia is considered a safer and more effective method of relieving pain in labor as compared to intravenous or oral analgesia. In a 2018 Cochrane review of studies which compared epidural analgesia with oral opiates, some advantages of epidural analgesia included better efficacy, fewer instances of naloxone use in newborns, and decreased risk of maternal hyperventilation. Some disadvantages of epidurals included an increase in the number of Caesarian sections required due to fetal distress, a longer labor, increased need for oxytocin to stimulate uterine contractions, an increased risk of low blood pressure and muscle weakness, as well as fever. However, the review found no difference in overall Caesarean delivery rates, and no evidence of negative effects to the baby soon after birth. Furthermore, the occurrence of long-term backache was unchanged after epidural use. Complications of epidural analgesia are rare, but may include headaches, dizziness, difficulty breathing and seizures for the mother. The child may experience a slow heartbeat, decreased ability to regulate temperature, and potential exposure to the drugs administered to the mother.


title: Epidural administration

text: There is no overall difference in outcomes based on the time the epidural is administered to the mother, specifically no change in the rate of caesarean section, birth which must be assisted by instruments, and duration of labor. There is also no change in the Apgar score of the newborn between early and late epidural administration. Epidurals other than low-dose ambulatory epidurals also impact the ability of the mother to move during labor. Movement such as walking or changing positions may help improve labor comfort and decrease the risk of complications.


title: Epidural administration

text: Epidural analgesia has been demonstrated to have several benefits after other surgeries, including decreasing the need for the use of oral or systemic opioids, and reducing the risk of postoperative respiratory problems, chest infections, blood transfusion requirements, and myocardial infarctions. Use of epidural analgesia after surgery in place of systemic analgesia is less likely to decrease intestinal motility which would occur with systemic opioid therapy through blockade of the sympathetic nervous system. Some surgeries that spinal analgesia may be used in include lower abdominal surgery, lower limb surgery, cardiac surgery, and perineal surgery.


title: Epidural administration

text: The injection of steroids into the epidural space is sometimes used to treat nerve root pain, radicular pain and inflammation caused by conditions such as spinal disc herniation, degenerative disc disease, and spinal stenosis. The risk of complications from steroid administration is low and complications are usually minor. The specific drug, dose, and frequency of administration impacts the risk for and severity of complications. Complications of epidural steroid administration are similar to the side effects of steroids administered in other manners, and can include higher than normal blood sugar, especially in patients with type 2 diabetes.


title: Epidural administration

text: An epidural blood patch consists of a small amount of a person's own blood is injected into the epidural space. This is done as a method of sealing a hole or leak in the epidural. The injected blood clots at the site of the puncture, closes the leak, and modulates CSF pressure. This may be used to treat post-dural-puncture headache and leakage of cerebrospinal fluid due to dural puncture, which occurs in approximately 1.5% of epidural analgesia procedures.


title: Epidural administration

text: The use of epidural analgesia and anesthetic is considered safe and effective in most situations. Epidural analgesia is contraindicated in people who have complications such as cellulitis near the injection site or severe coagulopathy. In some cases, it may be contraindicated in people with low platelets, increased intracranial pressure, or decreased cardiac output. Due to the risk of disease progression, it is also potentially contraindicated in people with preexisting progressive neurologic disease. Some heart conditions such as stenosis of the aortic or mitral valves are also a contraindication to the use of epidural administration, as is low blood pressure or hypovolemia. An epidural is generally not used in people who are being administered anticoagulation therapy as it increases the risk of complications from the epidural.


title: Epidural administration

text: In addition to blocking nerves which carry pain signals, local anesthetics may block nerves which carry other signals, though sensory nerve fibers are more sensitive to the effects of the local anesthetics than motor nerve fibers. For this reason, adequate pain control can usually be attained without blocking the motor neurons, which would cause a loss of muscle control if it occurred. Depending on the drug and dose administered, the effects may last only a few minutes or up to several hours. As such, an epidural can provide pain control without as much of an effect on muscle strength. For example, a woman in labor who is being administered continuous analgesia via an epidural may not have impairment to her ability to move. Larger doses of medication are more likely to result in side effects. Very large doses of some medications can cause paralysis of the intercostal muscles and thoracic diaphragm responsible for breathing, which may lead to respiratory depression or arrest. It may also result in loss of sympathetic nerve input to the heart, which may cause a significant decrease in heart rate and blood pressure. Obese people, those who have given birth prior, those with a history of opiate use, or those with cervical dilation of more than 7 cm are at a higher risk of inadequate pain control.


title: Epidural administration

text: If the dura is accidentally punctured during administration, it may cause cerebrospinal fluid to leak into the epidural space, causing a post-dural-puncture headache. This occurs in approximately 1 in 100 epidural procedures. Such a headache may be severe and last several days, or rarely weeks to months, and is caused by a reduction in CSF pressure. Mild post-dural-puncture headaches may be treated with caffeine and gabapentin, while severe headaches may be treated with an epidural blood patch, though most cases resolve spontaneously with time. Less common but more severe complications include subdural hematoma and cerebral venous thrombosis. The epidural catheter may also rarely be inadvertently placed in the subarachnoid space, which occurs in less than 1 in 1000 procedures. If this occurs, cerebrospinal fluid can be freely aspirated from the catheter, and this is used to detect misplacement. When this occurs, the catheter is withdrawn and replaced elsewhere, though occasionally no fluid may be aspirated despite a dural puncture. If dural puncture is not recognized, large doses of anesthetic may be delivered directly into the cerebrospinal fluid. This may result in a high block, or, more rarely, a "total spinal", where anesthetic is delivered directly to the brainstem, causing unconsciousness and sometimes seizures.


title: Epidural administration

text: Epidural administrations can also cause bleeding issues, including "bloody tap", which occurs in approximately 1 in 30–50 people. This occurs when epidural veins are inadvertently punctured with the needle during the insertion. It is a common occurrence and is not usually considered a problem in people who have normal blood clotting. Permanent neurological problems from bloody tap are extremely rare, estimated at less than 0.07% of occurrences. However, people who have a coagulopathy may have a risk of epidural hematoma, and those with thrombocytopenia might bleed more than expected. A 2018 Cochrane review found no evidence regarding the effect of platelet transfusions prior to a lumbar puncture or epidural anesthesia for participants that have thrombocytopenia. It is unclear whether major surgery-related bleeding within 24 hours and the surgery-related complications up to 7 days after the procedure are affected by epidural use.


title: Epidural administration

text: Rare complications of epidural administration include formation of an epidural abscess (1 in 145,000) or epidural hematoma (1 in 168,000), neurological injury lasting longer than 1 year (1 in 240,000), paraplegia (1 in 250,000), and arachnoiditis, Rarely, an epidural may cause death (1 in 100,000).


title: Epidural administration

text: If bupivacaine, a medication commonly administered via epidural, is inadvertently administered into a vein, it can cause excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures as well as central nervous system depression, loss of consciousness, respiratory depression and apnea. Bupivacaine intended for epidural administration has been implicated in cardiac arrests resulting in death when accidentally administered into a vein instead of the epidural space. The administration of large doses of opioids into the epidural space may cause itching and respiratory depression. The sensation of needing to urinate is often significantly diminished or completely absent after administration of epidural local anesthetics or opioids. Because of this, a urinary catheter is often placed for the duration of the epidural infusion.


title: Epidural administration

text: In many women given epidural analgesia during labor oxytocin is also used to augment uterine contractions. In one study which examined the rate of breastfeeding two days following epidural anesthesia during childbirth, epidural analgesia used in combination with oxytocin resulted in lower maternal oxytocin and prolactin levels in response to breastfeeding on the second day following birth. This results in a decrease in the amount of milk produced.


title: Epidural administration

text: An epidural is injected into the epidural space, inside the bony spinal canal but just outside the dura. In contact with the inner surface of the dura is another membrane called the arachnoid mater, which contains the cerebrospinal fluid. In adults, the spinal cord terminates around the level of the disc between L1 and L2, while in neonates it extends to L3 but can reach as low as L4. Below the spinal cord there is a bundle of nerves known as the cauda equina or "horse's tail". Hence, lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural space without puncturing the layer immediately below containing CSF under pressure.