Mentoring and Support Crucial For Teens With Chronic Pain

March 24, 2016 / Thomas Cohn, MD

New research out of Canada suggests that doctors should ensure that teens who are battling chronic pain and illness should have a support system in place to address their mental health, as it can help manage physical symptoms.

The study was small, but the findings speak to a larger issue that oftentimes gets overlooked when it comes to helping adolescents with chronic pain. For their study, researchers conducted an eight-week study with 28 kids between the ages of 12 and 17 who had been diagnosed with various chronic pain conditions. The group was split in two, with one group participating in the iPeer2Peer program.

Those in the treatment program were partnered up with an adult between the age of 18 and 25 who had also been diagnosed with a chronic condition. The mentors needed to undergo a 20-hour training session prior to being paired up with a mentee. The pairs talked via Skype twice a week for at least 20 minutes a session for the first two weeks, then at least once a week for the remaining six weeks. Researchers noted than sessions routinely ran about twice as long as the minimum 20-minute scheduled session. Mentors shared advice, offered emotional support and addressed any concerns or questions the mentee had.

Mentoring Chronic Pain

At the conclusion of the eight weeks, researchers uncovered:

Mentees reported significantly higher self-management skills and more satisfaction with their ability to cope with pain after completing the program.

Mentees in the program said they were satisfied with the program and would recommend the treatment to a friend.

Mentors responded that they enjoyed the sessions as well.

Researchers believe that showing teenagers that they don’t have to fight their battles alone can be a significant step in helping them cope with their chronic condition.

“Young people with chronic pain can become socially isolated and many have never met another person with chronic pain,” said lead study author Sara Ahola Kohut, a pediatric health psychologist at The Hospital for Sick Children in Toronto. “By having trained mentors, young people who are only a couple years older than the teens, teach coping strategies, we believed the pain coping skills might be easier to learn and practice.”

Kohut concluded that anywhere from 11 to 38 percent of children and adolescents deal with chronic conditions at that stage of their life, so we need to start addressing the issue. This program may be the answer.

“The program is easily accessible, teenagers liked it, and it helped improve the teenagers’ ability to cope with pain.”

Sleep, Insomnia, and Pain

March 8, 2016 / Thomas Cohn, MD

Difficulty sleeping is a common problem with patients in pain. Good quality sleep throughout the night often reduces the intensity and perception of pain. There are many causes and not a single solution for poor sleep. Pain in the neck and low back regions can cause discomfort within a short amount of time while lying down. Chronic pain can also cause anxiety and depression and that can contribute to sleep issues. To make matters even more complicated, the medications used to control pain may have side effects that impair sleep. Patients with chronic pain may also have other medical conditions that cause difficulty with sleep.

Sleep Postitions

Treating sleep problems in patients with pain is often quite complex. The first step in treating sleep-related pain is to make sure the patient has good positioning of the body with regards to the spine in a neutral position. For neck pain this would be using a pillow that supports the head without having the neck bent if lying on the side, or a thin pillow with a slight neck roll if lying on the back. Low back patients need pillows to support their position if lying on the side between the knees and sometimes supporting the stomach or against the back. Having multiple pillows to maintain a good position is normal. If lying on the back, having a pillow under the knees improves the low back position reducing stress on those muscles. A bed that accommodates and maintains natural curvatures of the body, such as a memory foam mattress or an adjustable air bed also may be helpful to reduce stress and pain on either the neck or low back.

Pain, Anxiety, and Sleep

Pain itself can cause sleep difficulties related to anxiety and depression. The centers in the brain that interpret pain signals and those associated with anxiety and depression are in the same regions. Often as one develops chronic pain, anxiety also occurs and contributes to sleep problems. Not treating this problem adequately can worsen the pain since these areas of the brain tend to interact. Often anxiety has been treated with benzodiazepines like:

Valium
Ativan
Xanax
clonazepam

These medicines induce the first phases of sleep but not the deeper sleep that is needed. Anxiety in pain patients is often a symptom of depression, and is not well treated with the above medications. Using antidepressants actually treats the chemical imbalances that occur and with the right medications the symptoms improve as well as the sleep.

In pain patients, recent studies show that sleep problems are often mixed with significant concern about not being able to sleep. Patients tend to concentrate on not being able to sleep and this then becomes the reality. More drugs with side affects is typically not the best solution. More effective treatment is the use of cognitive behavioral therapy (CBT). This is a psychological method of retraining the brain to think in a constructive fashion and this reduces the anxiety about sleep and anxiety. Studies have found the use of CBT to be equally or more effective in managing sleep problems in pain patients than the use of medications.

Traditional pain medications like opioids also have negative effects on sleep. These drugs tend to reduce deep sleep and increase the shallow phase 2 sleep. Deep sleep phases are the periods that are necessary to feel rested. The more potent opioids also have a tendency to increase both obstructive sleep apnea and central sleep apnea. Both decrease oxygen levels in the body and lead to frequent awakening. Sleep apnea will markedly decrease deep sleep and the quality of sleep.

New Sleep Medications

Ease of falling asleep, being able to stay asleep, and having deep restorative sleep measure good quality sleep. With good sleep, one should feel well rested and have less pain. As noted above, one of the best management techniques for sleep is using cognitive behavioral therapy. Medications are starting to get better. The newer sleep medications over the last ten years like Ambien and Lunesta help induce sleep, they do not keep one asleep and may cause hangover and odd behaviors like sleep walking. Melatonin type medications also induce sleep, can be used safely long-term, but do not maintain prolonged deeper sleep. The newest medication is Belsomra and this appears to be inducing and maintaining sleep. One old time medication, doxepin at very low doses also seems to have similar properties.

If one has pain and sleep difficulties, it is important to discuss the problem with your pain physician. A trial of simple solutions, either CBT or melatonin type medications is reasonable. If the sleep problems are ongoing, being evaluated by sleep specialists and having a sleep study done is beneficial. Sleep apnea is common in pain patients and treating these problems is essential in managing sleep. Ongoing sleep problems may require a combination of solutions since multiple factors are probably present. Like managing pain, sleep is complex and often difficult to find a solution to improve the situation.

Smoking Worsens Chronic Back Pain

February 22, 2016October 25, 2017 / Thomas Cohn, MD

New findings out of the Association of Academic Physiatrists Annual Meeting revealed another reason why you shouldn’t take up smoking if you want to have a healthy body. Researchers say smoking has been linked to worsening of degenerative disc disease in the cervical spine.

Degenerative disc disease is a natural process that occurs as we age, but that doesn’t mean everyone will suffer from painful symptoms. The condition occurs as the cervical discs between our vertebrae slowly break down over decades of use. If the condition worsens too much, the jelly-like central portion of the disc can rupture, causing pain and irritating local nerves. Living a healthy lifestyle can help prevent a speedy degeneration of your discs.

Smoking, on the other hand, has the opposite effect. Lead researcher Dr. Mitchel Leavitt said smoking can harm the small blood vessels in your back, which can make it difficult for oxygenated blood to flow in your back, exacerbating degenerative disc disease.

“Smoking is not healthy for a person’s intervertebral discs given the risk of developing microvascular disease – a disease of the small blood vessels – due to nicotine abuse,” Dr. Leavitt said. “Intervertebral discs receive their nourishment from the microvasculature that line the endplates on either side of each disc; when these blood vessels are damaged, the discs do not receive nourishment and this may speed up the degenerative process.”

Chronic Back Pain and Smoking

To understand how smoking contributed to chronic back pain, researchers evaluated CT scans of 182 patients who did not necessarily have back pain. 34 percent of individuals identified as smokers, and five cervical discs were given a grade on a 0-3 point scale with a 3 score denoting severe disc height loss. A five-disc total score between 0-15 was assigned to each individual.

After looking at the available data, researchers found that on average, smokers scored 1-point higher on the degeneration scale compared to non-smokers.

“This is another example of the detrimental effects of smoking. Tobacco abuse is associated with a variety of diseases and death, and there are lifestyle factors associated with chronic neck pain,” said Dr. Leavitt. “Pain and spine clinics are filled with patients who suffer chronic neck and back pain, and this study provides the physician with more ammunition to use when educating them about their need to quit smoking.”

So if you want to give your lower back the best chance to avoid chronic pain from degenerative discs, give up your smoking habit.

Minnesota Doctors Not Sold on Marijuana

January 18, 2016 / Thomas Cohn, MD

The Minnesota medical community is, according to January 12, 2016 article in the Star Tribune, not sold on medical marijuana. In reality, this is not very surprising. There are probably many reasons, but the most obvious reason is the idea that medical professionals like to base all their care on a scientific basis. From taking a history, to performing an exam and determining the tests and treatment, medicine is more of a science and depends on evidence for diagnosis and treatment of problems. If there is not evidence to support a treatment, medical professionals are trained to be skeptical of its use and purpose. Currently, medical marijuana definitely falls into this category.

Most important to the debate on medical marijuana is that there is very limited scientific research supporting many of the claims of usefulness. The research with regards to the management of most medical problems is related to a few small studies, and there are hardly any definitive studies that show significant positive value, and the study designs are often not blinded/controlled with any large number of participants. For pain management there is mostly incidental case report-type studies without mentioning which specific cannaboids are effective. Since cannabis plants contain over 100 different cannaboids and other compounds, using so many chemicals at once in a relative uncontrolled mixture is not a scientific approach to treatment. In a way it is like throwing a grenade at a problem and hoping everything does not blow up in your face.

Fixing The Marijuana Issues

The proponents of medical marijuana often bring to the table multiple examples of the wonderful help that various individuals have experienced with its use. However these are individual cases, and not necessarily what will occur with every individual. When a new drug is brought to market, we all want to have extensive testing performed to make sure it is safe, to ensure it performs correctly and that the same effect will occur each time it is taken. With medical marijuana we do not know most of these things. We have no idea what exactly is in the extracts, and we have no studies on how animals or humans will react to the compounds over time. Any other drug besides marijuana with this lack of scientific research would never even be considered to be used widely as an intervention. It is not surprising most medical professionals have a huge degree of skepticism about certifying patients to use medical marijuana and endorsing treatment.

In pain management there are many treatments available that have been shown to be reasonably effective. A pain management expert often can help a person through the maze of management options and help find an effective plan. There are a portion of patients with extremely complex problems without great solutions to control symptoms at this time. Failure of standard treatments may be a reason to want to try medical marijuana. Those who do go this route need to know at this time it should be considered truly an experimental treatment, and that the short and long term side effects and problems are not really known. There are a huge number cannaboids contained in medical marijuana, and while some may be helpful, others can be harmful. It may be a significant risk to use these compounds and until they are better studied and understood, and it is unlikely that the medical field will endorse such treatment without serious reservation.

A Bed for Back Pain

December 23, 2015May 10, 2016 / Thomas Cohn, MD

As Shakespeare wrote, “Sleep, perchance to dream…” is often an evasive quality for those who have chronic back pain. Patients are always asking if they should get a new mattress or bed to help with their back pain. Television commercials are always bombarding us with information that if your mattress is over eight years old, you need a new bed. If you decide to replace your mattress, there are so many to choose from. In reality, a good bed should last for years (my current bed is 15 years old) and the materials of today’s beds are meant to last a long time. The main issue is finding a good quality comfortable bed.

Back Pain – What To Look For In a Bed

If you have pain, the mattress should allow the spine to stay in a neutral position while lying down, usually on one’s back or side. The spine has several natural curves from the head to the pelvis. Unfortunately, some people have more curvature than others, but no one has a flat back. The mattress and its cushioning should conform and support the curves of the body so that they stay in a neutral and unstressed position. The bed topper and the central bed material should provide this support comfortably.

Over the last ten to twenty years, three new types of mattresses have taken hold; memory foam, latex, and adjustable airbeds. A combination of these technologies is often used together to develop the best overall experience. Basic mattresses are a core of some type of foam rubber that have layers of more expensive latex foam, cool memory foam and some sort of fiber toppers. Airbeds have a core designed with an adjustable air bladder and then often have similar toppers as other mattresses. Each combination has its advantages.

Memory foam mattresses and toppers have been gaining popularity over the recent years. It was first developed for the space program, and now has many slightly different formulations. Different densities of foam now are layered together and respond to weight and temperature in order to contour to that shape and also absorb motion. Since they are dependent on the body temperature to mold and shape to form, they tend to be warm to sleep upon. If you are always to warm, they may not be best choice unless it is made of newer technology that keeps one cool.

Latex mattresses are made of natural or synthetic foam rubber. They tend to be very uniform in support and may be a bit bouncy. They tend to be a bit firmer overall in support. If you like a firm bed, latex mattresses will definitely provide this type of support.

Air mattresses are beds that use an adjustable air chamber system to support a frame with foam layers surrounding it. Instead of the old coil spring mattress with one level of stiffness, the core is now a sophisticated, adjustable air chamber. The mattress then conforms and places even pressures on all areas of the body. King or queen mattresses have different adjustments for each side of the bed, so if partners like different settings, that is possible. Further, if you like to change the hardness of the bed at times, it is easy to fine-tune the stiffness to your position or preferences.

What’s The Best?

The picture of the best mattress often becomes somewhat more confusing. Many mattresses are a combination of multiple forms. The core of the mattress is either coil springs, latex foam, or an air chamber with choices of multiple types of cool memory foam and latex comfort foam, with some cloth/fiber padding as topper material that is about 3 to 4 inches thick above the core material. The combination of core and topper determine the comfort for each individual.

The last subject that arises with beds is the adjustable frame bed. Some of the beds have heads that elevate, adjusting to different angles, some have head and legs that have adjustable positions. These beds have traditionally been for people who have breathing problems at night and need the head elevated, or those who have difficulty moving in and out of bed. Some people like these beds if they read or watch television in bed. Generally, the adjustable bed is a luxury, using a couple of extra pillows can be a cheaper and easier solution than a fancy adjustable bed frame.

Finding the right mattress can be a challenge. At this time, I advise that you make sure the topper on the mattress is high quality, is comfortable and it should contour to your spinal curves while on your back or sleeping on your side. The core material may be a personal preference, but with an air chamber that is adjustable, this allows you to change your mind and make changes as your sleeping situation may change. All good mattress seem to be expensive. Choose wisely, keeping cost, comfort and future flexibility in mind.