Why Difficulty Sleeping Is Like Living With Chronic Pain

28201632 – woman suffering from stress or a headache grimacing in pain as she holds the back of her neck with her other hand to her temple, with copyspace

Chronic and acute pain often interferes with sleep. Since a third of our lives are spent sleeping or trying to sleep, having an issue getting good sleep can be a major issue. There are many problems that interfere with sleep, and many pain patients have difficulty sleeping. Sleep is similar to pain, in that it is a complex process, and many things can affect our sleep. Sometimes the solution to better sleep is simple, but more often the problem and solutions are complex.  

Why Recent Guidelines on Sleep Fall Short

The latest issue of JAMA came in the mail today and had two articles related to sleep. The first was on chronic insomnia and the new guidelines for its management. The second article was on restless leg syndrome (RLS). The “guidelines” were put out by the American College of Physicians (ACP) and written by primary care physicians and health care administrators. To be valuable, guidelines really need to be written by experts in the field of the guideline, and sleep specialists can be credentialed in Neurology and Internal Medicine with a specialty of Respiratory Medicine. These experts were not the ones to write these guidelines. If a patient wants only entry level advice on sleep, these may be okay, but for those suffering from chronic sleep issues, consulting an expert would serve most patients significantly better. It is shame that leading national organizations like the ACP and JAMA publish minimally useful information.  

Since I have been in practice for a number of years, learning some some of the basic treatment options to improve sleep is not difficult. If a patient is having difficulty sleeping, always start with a good history and physical exam. The history often tells significant information with regards to the nature of the sleep problem. Treating sleep is usually more complex than guessing the right medications. The most important first step is good habits prior to going to sleep. The easy things involve reducing caffeine intake, especially in the afternoons and do not drink it at night. Alcohol also does not help with sleep; it often will wake one up in the middle of the night. Technology is also a horrible actor; the blue light of cellphones and computers as well as television will stimulate people and prevent sleep. Lastly, do not exercise vigorously in the evenings; this also wakes up most people.

Solving Sleep Problems

If a person has addressed the simple sleep issues and they are still having sleep problems, then finding a solution will often require some expert intervention. Since there are many problems that affect sleep, obtaining a medical sleep consult by a specialist is worthwhile. Problems like sleep apnea are often an issue. Finding medical problems that need management can reduce interference with sleep. If nothing is found to be a problem by an expert, then solutions to what seems to be reducing sleep can be initiated. Many people cannot relax enough to go to sleep, and psychological based treatments like mindfulness or cognitive behavioral therapy are indicated. Few patients may need some sort of medications, but these need to be closely monitored for side effects.

Most experts have not found that a particular type of bed or pillow makes any significant difference. If I am asked about whether a person should buy a new bed, it is probably only necessary if the current one is totally broken. Pillows are really a matter of personal preference, but they need to keep the neck in a neutral spine position. Usually spending lots of money on beds and pillows is not a good solution for improved sleep.

The patient with chronic pain is often no different from any other patient with sleep difficulties. Correct the simple things with regards to sleep hygiene first. If a person continues to have sleep problems, they should see a sleep specialist who can often help find the most appropriate intervention. Expensive beds and pillows are not usually a good investment. If you need a new bed, buy either a bed with a memory foam type top, or an air adjustable bed so the firmness can be adjusted depending on how you feel. Beds with adjustable frames that raise the head are sometimes good for those with breathing problems at night. Most importantly, good sleep hygiene is the first issue to solve, and if the problems persist, ask to see a sleep expert.

New Low Back Pain Guidelines From The ACP

 

Low back pain treatmentIn the last week, the American College of Physicians (ACP) published new guidelines for the care of low back pain. The guidelines are their recommendations based on the available research on the subject. The most important thing to remember is this information is designed for physicians to assist with the management of particular problems.

However, the recommendations are only as good as the knowledge and ability of those who put together the data. These guidelines provide some reasonable information, but they do not contain significant information from board certified pain practitioners who are treating the problem every day. The reason why we need to highlight this issue is because the guidelines attack back pain as if it has one single cause, which we know is not always the case.

Where The Guidelines Fall Short

For the pain practitioner and as it should be for every doctor, pain is one symptom, and the low back region covers a large number of structures that can cause problems. A diagnosis is based on a history of symptoms, a physical exam, and then the application of medical knowledge to determine the causes related to the problem.

The new guidelines move away from coming up with a specific diagnosis of the pain problem. They also recommend any number of treatments that have a limited scientific basis, like acupuncture and spine manipulation, and they did not address medications very well. Muscle relaxants are recommended as well as duloxetine (Cymbalta), while many more common medications like Celebrex were not studied. The guidelines also recommend many psychological therapies and exercises that are not readily available or not covered by insurance.

Treating Back Pain

Guidelines are meant to serve as a road map to help practitioners establish appropriate treatment for patients. The new ACP guidelines lack instruction on establishing appropriate diagnoses and true evidence-based treatment alternatives. The guidelines appear to be the answer to what is the cheapest way to get a complex problem patient out of an office. They recommend everything but appropriate diagnostic testing, referrals to experts in pain, or advice on all the non-opioid options available and when to use them. These guidelines made headlines in the national news, but they surely are not truly newsworthy.

Acute, subacute, and chronic low back pain all have different meanings and can be quite well treated with a variety of interventions. It is true that most acute back pain is short lived, but primary care physicians should learn much more about all the causes and treatments available.  For the patient, telling them “No matter what you do, it usually gets better in a month,” as these guidelines suggest, is poor quality care. No patient wants to be sidelined for a month, and they want to have a definitive diagnosis and treatment plan. These guidelines fall short of offering the best care for each patient with back pain.

Would Mandatory Opioid Registry Checks Solve Painkiller Abuse?

Mandatory Opioid ChecksThe Minnesota legislature has a proposed law to make checking the Minnesota Prescription Monitoring Program database (PMP) mandatory prior to prescribing any opioid medication. The purpose of the law is to help identify people abusing medications and to prevent the explosion of overdose-related deaths.

Unfortunately, this is another oversimplification of the opioid problem in our country. Abuse of opioids is a very real problem. The solution is much more complex then checking a database for the number of prescriptions being taken. Mandating this step will only have a very minor effect on the problem of opioid abuse.

Opioids Abuse And The Database

Opioid abuse is a very complex problem. There are many people who have very difficult to treat pain problems that are dependent on these medications, and they take them on a very reliable basis without abuse. Currently, most pain physicians, including my practice, have a variety of steps they take to reduce the potential for abuse. One of the easiest is to look at the PMP database. We sometimes find abnormalities of behavior there, but it is not that common. Most often we find the patient is using both an opioid and a drug for anxiety that can cause a significant interaction. Then we need to advise a patient on these issues.

Other steps taken include a comprehensive medical exam for appropriate problems to be treated and finding alternative treatment plans. Believe it or not, the worst problem is obtaining insurance company approval for more expensive options with better outcomes and less risks to the patient. Other steps taken include drug testing, checking state criminal databases and evaluating psychological stability before prescribing. For those wondering, our practice does check the PMP for everyone for each refill.

Mandatory Checks?

Mandatory checking of the PMP does not significantly help solve the opioid abuse problem. It is only a feel good step for politicians to say they are doing something. The problem runs much deeper. First off, a lot of people who are abusing opioids should probably never have been placed on the medication. The next step is that they should not be on them for any length of time – they may be okay for a very acute problem – but then they need to be stopped. Addiction is a medical condition. It is tough to treat and programs to help with addiction need funding and staff, and this needs to be promoted.

If the legislature wants to have a positive role in the addiction crisis, then they should be mandating insurance coverage for alternative treatments for pain besides opioids. Alternative treatments include everything from prolonged physical therapy, massage, chiropractic, and different medications, to comprehensive pain programs and implantable pain control devices. Obtaining insurance approval, especially from Medicaid or Medicare, is time consuming and often almost impossible. Physicians are extremely frustrated by the obstacles put up by insurance companies when better and cheaper alternatives are routinely denied in managing pain.

The last difficulty in understanding pain and the opioid crisis goes beyond the problems of addiction. Pain is extremely complex and one of the main tools to control symptoms is opioid medication. This is the same tool we have used for over 150 years. A third of the world population struggles with pain problems. Virtually no dedicated funding goes to research on pain compared to other medical problems. Our knowledge level in regards to pain as a disease is at the level where cancer was in about 1950. If the world wants to tackle the problem of opioid abuse, it really needs to fund research on all aspects of pain to solve the issues suffered by a third of the world population.

Are Stretch Studios The Next Big Fitness Wave?

stretching benefitsOne of the three key aspects of exercise is stretching. The other two are strengthening and conditioning. When one has pain, a component may be tight muscles. A recent article in the New York Times took a look at the new fad of stretching studios. There have been all kinds of health and fitness crazes, but this was something new.

There are many different types of exercise gyms, from the bare bones centers to the multimillion-dollar health clubs to the specialty studios for yoga. Now the new kid is the studio that works individually with a client to increase a person’s flexibility through muscle stretching. Athletes and those with a wide variety of injuries or conditions like neck and low back pain have muscle tightness. Muscle pain with lack of full range of motion often contributes significantly to pain.

Stretching Benefits

The advent of the “stretch” centers, the studios that concentrate on working with people on muscle stretching, is an outcome of our world of pain. Muscle pain is common in athletes due to strengthening without also concentrating on maintaining full muscle length and joint mobility. In the person with neck or low back pain, muscle tightness occurs due to the muscles contration in an effort to prevent someone from moving a painful area. In either cause, tight muscles and lack of joint range of motion are causes themselves for pain.

Stretching is an essential component of exercise. Being an ancient doctor, the reference book of my time was “Stretching” by Bob Anderson, and it was an easy to understand guide to stretching any region of the body. Now, the Internet or your phone’s apps can be an easy source of exercises to stretch any part of the body. Routines do not need to be complicated or take large amounts of time. Stretching for 5 to 10 minutes every day is extremely helpful to loosen up muscles. Sometimes, it takes multiple times a day that one has to stretch, especially if the problems are neck and low back pain. A stretch can be as simple as bending over to touch your toes or sitting on the floor and reaching for your toes.  A lot of people are stiff at the end of the day or first thing in the morning. Doing a stretching routine before going to bed and first thing in the morning can often help reduce tightness and pain especially at night and early in the day.

Advanced Stretching

The stretching studios are a bit higher level of stretching. A staff member works with a client to help them stretch a wide variety of muscles. They spend 45-60 minutes work on whole body flexibility. Getting all the muscles loosened up by stretching can be very relaxing. Supposedly the relaxation is similar to what is felt with a massage, but it would require more participation for the client.  

Physical therapy can also teach a person how to effectively stretch, especially a person who has had an injury. Working with a therapist is helpful to learn the correct techniques and to prevent further injury. Oftentimes a therapist will give a patient numerous exercises to perform, and doing the whole set could take 45 minutes. Once one understands the exercises, you can choose a few that cover the areas that need work so the whole routine can be done in hopefully 10 to 15 minutes at the most. The main message is tight muscles are often a source of pain, and learning and performing effective stretching routines daily can significantly improve function and diminish overall symptoms.

An Update On Daith Piercings

daith migraineI wrote my first article on Daith piercings about a year and a half ago. As many know, this has been advocated for the treatment of headaches. The questions I have been asked since that time have been numerous but the most common question is, “Will it work for me?” I obviously cannot tell if it work for anyone in particular. I have heard from many that it has helped them manage their migraine headaches. Most interesting to me was some of my regular patients have tried it successfully.

Daith Piercing Information

Daith piercings are a specific type of ear piercing. The ear cartilage midline toward the front of the ear is pierced. This type of ear piercing has been around for 3,000 years, but the name “Daith piercing” was probably started in the 1990’s. The placement of the piercing is at the entrance to the ear canal and has symbolic meaning as the “Guardian to the Gate.” This piercing can be quite painful, and since it is through bony cartilage, care must be given to keep the site clean and to prevent infection.

There are many types of headaches, and only certain types of headaches will respond to Daith piercings. Those most likely to improve are migraines that are sensitive to ear stimulation, and likely to be one sided in nature. Daily headaches may be caused be a variety of factors – most common are muscle tension and stress headaches. Muscle tension headaches are caused by neck muscles tightening up, often associated with the position one has while working on a computer. Stress type headaches are caused by psychological factors that make a person anxious.  The most common headache in my practice are those associated with neck problems; either from nerve and disc problems or from the joints in the neck causing pain. These types of headaches are best treated successfully by managing the underlying causes.

Managing Headaches

The headaches that have been managed by Daith piercings are those that are migraine headaches. If you have been diagnosed by a neurologist with definite migraine headache (not self diagnosed), Daith piercings may be a treatment option. Over the last 18 months of studying this subject, an interesting correlation occurred to me that this treatment was similar to acupuncture and vagal nerve stimulation. All these treatments seem to affect the vagal nerve via a branch near the ear, which sends signals back to the brain that may affect various neurotransmitters and hormones that lead to vascular headaches.

Unfortunately, the true scientific proof and medical evidence with regards to Daith piercings is not present. All the results when one researches the topic seem to be stories that it worked for them. There is some basis as noted above why it may work. For those who are interested, a few cautions should be remembered. First, this is specifically going to work best for migraine headaches. If you have frequent and sometimes severe headaches, and they are not easily managed, first see a medical doctor and possibly a neurologist and get a good diagnosis made, and try conventional treatment. The cause should be treated first and may be straight forward to manage. If the headaches are migraines, and they are not responding to management, Daith piercing may be reasonable. Physicians normally do not perform this procedure, so do not ask them to do it. Only get this done by someone who does body piercings and is familiar with this particular one. It is extremely important that meticulous care is performed before and afterwards to keep the area clean and free from infection. Since this is through ear cartilage, near the brain, an infection in the area can be very dangerous and should be treated aggressively by a doctor.

If you want to run a test before piercing, first try massaging the area of the ear when you have a headache and see if that makes a difference. Another possibility is to try acupuncture to see if that works. Most acupuncturists will report what they do is different than the piercing and this is not going to be equal to the piercing, but it may be safer and easier for a test. If you go ahead with a piercing, make sure you try to prevent an infection in the area of the piercing.