A Bed for Back Pain

/ 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.

Best Back Pain Bed

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.

Connecting The Medical Dots

/ Thomas Cohn, MD

Medicine today has become fractured. Primary care does basic analysis of a problem and basic care of that problem, while specialists have become such experts that they often can not see past their own rabbit hole. Few doctors are willing to look at the whole picture, analyze the patient as a person and all the problems presented. When someone takes the time and connects the dots, something special happens, and a path to the future can be found. For many patients, finding the doctor that has the experience to listen, to ask the right questions and to find the source of the problem can take years.

One Patient’s Dots Become Connected

Being a patient can be very frustrating. The other day I had a new patient with back pain, which is a pretty normal complaint for a referral. The patient was referred from an orthopedic spine surgeon who felt the patient was not a candidate for surgery. She was in her mid-30’s and had neck and upper back pain. She also has had longstanding scoliosis, a prominent curvature of the spine, and she had been to a number of previous providers for the problems and wants answers and a solution.

I usually work with a scribe. When I started my visit with the woman with scoliosis, she was fascinated. Within in a couple minutes and a few choice questions, my scribe saw a light in my brain go on and the discovery of the unifying diagnosis that no one in the past had a clue about. The patient had scoliosis, but had been double jointed, had shoulder and knee joint issues, had heartburn, and cardiac problems. She also had siblings that were double jointed. The unifying theme was a genetic-based connective tissue disorder, probably a form of Ehlers Danlos syndrome or Marfan’s disease. This will need to be confirmed by further testing and probably genetic testing.

Finding a diagnosis that connects the dots changes the whole picture of a problem. It no longer is a set of random of events causing pain. Now there is a reason and a pathway to follow to manage the problems. There is also knowledge about the course of the disease and a way to anticipate future medical issues.

Unfortunately, most patients never can connect the dots. Primary care physicians often do not have the time to address more than one problem at a visit. Specialists are only interested in their small corner of the world. My world often consists of looking at odd medical issues. Many times helping a patient means having to analyze the past, ask a few questions, closely listen to what a patient says, and bringing together the story to develop a pathway to the future.

The best patient care is provided by those providers who can see the big picture. Medicine has been fractured by the pressures to see as many patients as possible if providing primary care, or staying in your specialty only for others. Seeing the big picture and connecting the dots is a lost art. Changing lives for a patient means being able to go beyond the ordinary and really trying to answer the all their questions to uncover a long-term solution.

Headaches, Daith Piercings, and the Vagus Nerve

/ Thomas Cohn, MD

42212395_lOn November 28th, Science News published an interesting article on the science of the vagus nerve in the human body. It is the tenth cranial nerve in the body traveling from the brain to multiple organs in the body. It has thousand of fibers, and it influences functions throughout the body from the stomach and intestines to the heart and brain. The nerve has fibers that travel relatively superficially through the neck and in the skin of the ear. Stimulation of the vagus nerve in the neck has been used for a variety of disorders including many stomach and gastrointestinal problems as well as depression and seizures. Now the ear is the focus of treatment of number of problems by stimulating the vagus nerve as it travels in the region of the tragus of the ear.

The Vagus Nerve and Headaches

Headaches are extremely common. Many people struggle with the management of chronic daily headaches. Drugs are often not the answer, and can oftentimes make headaches worse. A lot of people also do not want to be putting more chemicals into their body. Finding suitable alternatives is difficult. Treatments for headaches run the gamut from diets to all kinds of supplements to stress management. Alternative medicine also has a number of treatments from chiropractic adjustment to acupuncture. Now there may be link to why these therapies work in terms of traditional medical knowledge, it is not just a coincidence they are effective.

Daith piercings and regionalized acupuncture for headache relief may now have a scientific root in the vagus nerve. This nerve has sensory branches that travel in the ear in the region of where the targets for acupuncture are and where a Daith piercing is placed. Electrical stimulation of the ear and vagus nerve has been done to treat headaches, depression, memory loss, and seizures. The vagus nerve has control over a variety of the body’s hormones, including acetylcholine and norepinephrine. The balance of these hormones can be affected by stimulating branches of the vagus nerve. Electrical or mechanical stimulation in the ear can accomplish changes to the branch of the vagus nerve and thus affect any process influenced by this nerve. Headaches have been known to be affected by vagal stimulation, and some have found pain relief through nerve stimulation.

As noted above, some headaches respond to vagal stimulation and improve, while others don’t. There are multiple ways to stimulate the nerve – electrical stimulation, mechanical stimulation as well as medication stimulation. Acupuncture, massage and Daith piercings provide mechanical stimulation of the region and possibly the nerve. Some varieties may respond to different types of stimulation. If your headaches have a vagal component, probably ear massage, electrical stimulation or acupuncture trials will determine if this may be helpful. If those work, consideration of Daith piercing for headaches may be aligned with your treatment strategies. If the above is not helpful, working with a neurologist, a  headache specialist or pain specialist may also be helpful to find other solutions.

New Laws on Chronic Pain and Medical Marijuana in Minnesota

/ Thomas Cohn, MD

Medical Marijuana chronic pain minnesotaEarlier this month Minnesota added intractable pain to the list of conditions that qualify for medical marijuana. It was a decision made by the Commissioner of Health, Dr. Ehlinger, in accordance to provisions of the legislation passed. In August of next year patients will be able to obtain prescription cannabis through the state approved pharmacies if they have been qualified. The exact rules are not yet in place, but there are some clear indicators of restrictions will be present. It is also not homegrown marijuana or any other marijuana; it is just from approved dispensaries that are strictly controlled.

Intractable pain in the State of Minnesota is chronic pain that has failed to be adequately managed by traditional medical care. This means that one has to have tried to manage the pain, gone through what is considered acceptable and approved treatment regimens, likely medication, physical therapy and possibly invasive management, and these treatments have been unsuccessful. One cannot just say they have pain, not have a diagnosis, and not go through standard treatments and expect to be able to obtain medical cannabis. Lastly, it is likely that two qualified medical providers (not just one) will both have to evaluate you and approve, and that the pharmacist at the dispensary also will have to agree.

Intractable Pain and Medical Marijuana

If you have chronic, intractable pain, it will not be easy to obtain medical marijuana. There will be good providers who will consider it an option as part of treatment. However, it is likely to be a choice only after one has failed reasonable standard treatments. The patient will have to be psychologically stable, and for most practitioners, it is likely that they will want them to be well controlled if they do have depression. Many providers will also look into any potential past substance abuse, and receiving both opioids and medical marijuana is likely not to occur. The better pain providers will likely want to closely monitor the patient receiving the alternative treatment and be in touch with the dispensary and pharmacist to know what is exactly being prescribed.

Medical marijuana is not a panacea. It is another possible treatment that may have benefit for some patients. The science and effectiveness behind its use is just in its infancy. Like all other medications there are side effects and problems. It is not an FDA or DEA approved substance and is very much considered experimental. Therefore it is not approved at this time by any insurance. Expect all management and treatments associated with its use to require cash (not credit card or check) payment up front for any services including doctor as well as pharmacy visits. Treatment is likely not to be cheap and it very well may not be readily available. Many physicians may be reluctant to be involved with this treatment, and as a patient, if you are at all mean, abusive, obnoxious, inappropriate, or otherwise difficult with a provider or their staff, this would likely close the door for further management with that office.

The State of Minnesota over the next several months will likely clarify the rules and regulations of medical marijuana for patients in the state. There will likely be a number of hurdles to climb to obtain the high quality pharmaceutical cannaboid for pain management. If it is the correct management tool when all else has failed, it may be worth the effort. It is not a simple solution, and it is not going to be a legal way to just get street quality marijuana for personal recreational use.

Improving Care by Listening and Explaining

/ Thomas Cohn, MD

An article in Sunday’s Star Tribune discussed a new program at the University of Chicago where doctors work to better explain medical problems to patients in order to provide better care. It sounds perfectly obvious to patients that doctors should be doing this, but doctors do not often understand this issue. What is obvious and simple to a doctor is a mystery to the patient. Being able to understand and explain the complex situation to a patient is what old time medicine is all about, and has often been lost in our high tech world.

Why The Change?

Medicine has changed significantly in the last twenty to thirty years. Technology and computers have taken a leading role. In the past, time was spent with the patient taking a history, doing an exam, and then discussing with the patient a plan of care. Afterwards a couple minutes was spent dictating a short note and checking off a sheet for a bill, then you were done. Most of the time was spent interacting with the patient. Today time is spent staring at a computer, first searching medical records, then filling out pages of forms to create a new report for the visit, then typing out orders for tests and bills. More time is spent interacting with the computer than with the patient. Government regulations demanding electronic medical records and ridiculous details for billing are partly to blame. Unfortunately, for many doctors it is easier to be quick and done than to spend time and effort explaining the complexities of the problem.

Listening Best Doctors St. Cloud

Pain management is no different, as many doctors do not spend the time to explain complex medical problems. Chronic pain is usually quite complex. There are often multiple factors contributing to the sensation of pain, and multiple areas affected. A lot of doctors just want things to be simple, and are not considering the full picture and how many issues may be present and interacting. Furthermore, they want to only deal with one problem at a time. Many pain doctors want to do only procedures and do not want to manage patients. Other pain doctors want to only deal with certain problems; they do not want to deal with medications, or have limited beliefs and are against many types of treatments from interventions to surgery. Finding a pain management doctor who is comprehensive, who understands the multiple complexities of pain problems and who can work with a patient as a partner to explain the problem and possible management options is difficult.

The solution to finding a good doctor is no easy task. There is no one place to look for a good doctor. Insurance companies set up panels of preferred providers that patients must pick from that have no correlation to quality. Physicians often have limited knowledge about their colleagues and their skills, and are even more reluctant to say anything negative about any other practice. Internet rating sites often have limited value since there is no good standard method to evaluate quality of medical care. Word of mouth from patients can sometimes be the best source of information. As rule of thumb, 90% of all physicians will do a good job, the trick is really to find the 10% who provide that exceptional level of care. Those 10% who are special in their level of skill will always be tough to find. When you do find those special quality providers, no matter what the profession, spread the word.