Pain and Sleep: A Real Nightmare

Pain and Sleep: A Real Nightmare

Chronic pain can interfere with work, exercise, activities, and general daily life.  At the end of the day, after suffering through pain to complete necessary daily tasks, a good night’s sleep sounds like the perfect cure.  However, for the majority of chronic pain sufferers, laying down for a solid eight hours is unfortunately not that simple. An estimated 90% of chronic pain patients treated at a pain management clinic describe seep issues, and 53% of these patients are diagnosed with moderate to severe insomnia.  

The correlation between pain and sleep trouble can become a vicious cycle.  Being in pain can prevent sleep, and lack of sleep can increase perception of pain, making it even harder to sleep, and so on.  Pain can either make it difficult to fall asleep, or cause frequent nightly wake ups. Chronic pain can be debilitating enough, that a patient cannot work or exercise, and is therefore not capable of using energy stores during the day to be tired enough to sleep.  Additionally, day time activities can keep the mind off of pain, but once the TV is off, the bedroom is dark and quiet, more focus can go on the pain, and making falling asleep more difficult. It is also common for pain to wake a patient up several times a night, due to a change in positions, or having to maintain the same position for too long.  Additionally, if the pain is treated with opioid medication, this too can potentially lead to insomnia, since these medications are known to interfere with the REM sleep, and can lead to respiratory issues while sleeping.  

Unfortunately typical tricks to help with sleep troubles may not be as helpful when the insomnia is secondary to pain.  Increasing mobility during the day can be a difficult, if not impossible feat. Some of the medications used to treat insomnia are dangerous to take with opioids, medications like Ambien and Xanax, and therefore patients are frequently left to choose between pain medication or sleep medication.  

There are, however, therapies that can help with sleep, which include both non-medication and medication based solutions.  First, it is recommended to make sure to practice good sleep hygiene. This includes a consistent bedtime, avoid caffeine in the afternoons, no strenuous activity four hours prior to sleep, and avoid naps.  If this does not improve sleep issues, psychotherapy can be beneficial. This can include deep breathing exercises, meditation, cognitive behavioral therapy, and other therapeutic techniques. If these don’t work, there are medications that can help which are safer to take with opioid medications, such as melatonin, benadryl, or prescription medications.  Additionally, acupuncture is a useful tool that can help with both the pain and the insomnia.  

Chronic pain can lead to difficult days, but unfortunately it frequently also leads to difficult nights.   Insomnia can be equally debilitating. If pain and insomnia are something you are suffering from, you can discuss options with your PCP or your pain management specialist, and they would be happy to help find the right resources to improve your daily, as well as nightly life.  

Resources

Bolash, R., & Drerup, M. (2019, November 18). How to Beat Insomnia When You Have Chronic Pain. Retrieved January 16, 2020, from https://health.clevelandclinic.org/managing-insomnia-for-those-with-chronic-pain/

Deardorff, W. (2016, December 12). Psychological Approaches for Insomnia. Retrieved January 16, 2020, from https://www.spine-health.com/wellness/sleep/psychological-approaches-insomnia

Mann, D. (2010, February 17). Pain and Sleep: When Chronic Pain Disrupts Sleep and Causes Insomnia. Retrieved January 16, 2020, from https://www.webmd.com/sleep-disorders/features/pain-sleep

Tang, N. K. Y. (2008, September). Insomnia Co-Occurring with Chronic Pain: Clinical Features, Interaction, Assessments and Possible Interventions. Retrieved January 16, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589931/

Fibromyalgia – The Ache That Won’t Go Away

Fibromyalgia

Fibromyalgia is a condition that many patients describe as a chronic, dull ache that is persistent all day long. People who have been diagnosed with it have associated fatigue, trouble with sleep patterns, numbness and tingling, and diffuse muscle pain. The theory is that people with fibromyalgia have heightened sensation of pain. Where a normal touch is perceived as mild to moderately painful. These tender areas are not just in one area such as the neck or back but diffuse throughout the body. People, at times, have categorized it like feeling like the flu. This widespread pain can range from mild to debilitating.

There are many treatment options for people with fibromyalgia. First, medications are beneficial and allow people to help manage their pain. These medications are varied and include muscle relaxers, neuromodulators, antidepressants, Low dose Naltrexone and NSAIDS. Opioid medications are not seen as a treatment choice.

Other treatment alternatives to help with this chronic pain include yoga, acupuncture, massage therapy, trigger point injections, and physical therapy. Many people try to avoid these therapies as these require them to use the muscles they perceive as painful. However, numerous studies show that exercise is the most important intervention to help with fibromyalgia.

Exercise helps patients gain strength, improve motion and foster better feeling of long-term health. People should start slow with stretching exercises and gradually increase to walking, water aerobics and even biking. Doing this a few minutes each day can turn into 30 minutes several times per week with the right plan. This will help with spasm, flexibility and endurance. Being active may initially increase the pain level these people experience but in the long term it will be beneficial and reduce pain levels.

The old saying of “no pain, no gain” is true for people with fibromyalgia but the rewards of putting in the work will lead to a better sense of well-being and improved pain scores. Making time for exercise throughout each week is essential for fibromyalgia treatment.

Depression and Pain

It is estimated that up to 85% of chronic pain patients suffer from severe depression.  Sometimes pain is a symptom of pre-existing depression, and sometimes the depression comes as a result of the effects of chronic pain.  With potentially one fifth of the US population suffering from chronic pain, understanding the association between depression and pain, and the subsequent treatment of the two, is becoming more and more important.  

The areas of the brain in charge of mood management include the prefrontal cortex, the amygdala, and the hippocampus.  Evaluation of the brain post-injury shows that body pain is controlled by most of the same regions of the brain. The chemicals in the brain associated with depression, such as serotonin and norepinephrine, play a major role in pain perception.  When the regulation of these chemicals fail, which can be the case with depression, pain perception is intensified. Additionally, autopsies performed on patients who had chronic depression showed a consistently smaller prefrontal cortex. This could potentially mean that depression can cause a physical change in the brain, therefore leading to a chronic, and possibly permanent change in the brain structure.  

Another correlation between chronic depression and pain is due to the similar impacts both can have on someone’s quality of life.  Depression can cause a lack of interest in hobbies, activities, socialization, and can therefore lead to isolation. Without the ability or desire to partake in everyday activities, more focus is paid to pain, which increases the perception of pain.  Pain can cause immobility, loss of ability to work or function, also leading to isolation, and therefore depression. Therefore, regardless of which came first, the onset of chronic pain or depression can either cause or increase the severity of the other.  

Being aware of the correlation between these two debilitating diagnoses can help lead to more effective treatment.  Physical therapy can help increase a patient’s strength and mobility, which is widely known to help with pain, however movement itself produces endorphins, the chemicals which help with happiness and reward, and therefore can decrease depression symptoms as well.  Psychotherapy is widely known to help with depression, however this can also help to alter a patient’s perception and focus on pain, and can either decrease the pain symptoms, or help a patient better cope with chronic pain symptoms. Many antidepressant medications are also used with chronic pain management, regardless of whether or not a patient has been diagnosed with depression as well.  

Overall, chronic pain can be extremely debilitating on its own, but unfortunately it commonly occurs with depression.  Treating one without acknowledging the other can lead to insufficient treatment of both, so understanding their correlation in onset, as well as treatment, can help patients improve their quality of life, both mentally and physically.  

References

Depression and pain. (2009, June). Retrieved January 14, 2020, from https://www.health.harvard.edu/mind-and-mood/depression-and-pain.

Sansone, R. A., & Sansone, L. A. (2008, December). Pain, pain, go away: antidepressants and pain management. Retrieved January 14, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729622/.

Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Retrieved January 14, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494581/.

Weight Loss and Improvements in Mental Health

Weight Loss

People today are busy with work, kids, and the normal activities of daily living. Many people do not make time for physical activities, eat on the run, and find little time for themselves due to the demands of life.

America is a country with over 70 million people considered to be obese. This means that 39.6% of our population is at risk for many health issues due to being overweight. Weight loss ads are all over the television as well as on the internet and social media.

Keeping these statistics in mind, we need to realize the importance of weight loss and understand all the benefits that come with losing extra pounds. Weight loss provides many advantages. People who lose weight will typically see lower blood pressures, lower blood sugars, increased physical activity, and improvements in pain as well. People with chronic back and joint pain note that their pain levels improve due to less stress on their body from the loss of excess weight.

People see a big improvements in their mental health. Studies show that losing weight leads to higher self esteem levels, more positive body image and feelings of contentment. After losing even 5-10% of body weight people report less depression, improved relationships, longer sleep duration and lower anxiety levels. Overall, weight loss has shown that people have an improved perception in their quality of life and more self confidence.

The weight loss journey may be tough and hard but the benefits and rewards in a person’s overall health are worth the time and effort. Today there are apps like My Fitness Pal or Lose It to help with this effort to keep track of food intake and exercise. This will help keep people accountable as they make the scales drop.

Set a goal and make a change. Help yourself become a healthier version of you!

MILD Procedure for Major Pain

It is estimated that around 80% of Americans will experience back pain in their lives.  There are many different causes of back pain, many different associated symptoms, and just as many treatments available.  One of the more feared treatments have been back surgery, since, until recently, it is most of the time severely invasive, and comes with an extended recovery time.  However, for certain types of back pain, a newer, less invasive procedure has been developed, aptly named Minimally Invasive Lumbar Decompression, or MILD. If lumbar spinal stenosis, or LSS, is the culprit, then MILD may be the treatment.

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In order to understand what the MILD procedure it, it is important to know what LSS is.  Lumbar spinal stenosis means a narrowing or pinching (stenosis) around the lower (lumbar) part of the spinal cord.  The spinal cord rests in the spinal canal, which is a tunnel in back part of the vertebrae. This tunnel is comprised of vertebral bones stacked on top of each other, with a disc in between them, and ligaments that run up and down keeping these bone/disc stacks both sturdy and mobile.  Years of wear and tear on the back can cause the discs to bulge, the bony joints to swell, or the ligaments to enlarge. Normally, the spinal cord has plenty of room in its spinal canal home, but if any of those wear and tear side effects occur, this can bulge, swell, or enlarge into the canal, and cause compression of the spinal cord.  This compression is responsible for back pain, and pain, numbness, tingling sensations that go down the legs. The pain is typically worsened with standing or walking, and relieved with leaning forward or sitting.

If the cause of the spinal stenosis and the pain symptoms is enlarged ligaments, that’s where the MILD procedure can help. This procedure involves a special, spoon-like tool that scrapes off the extra ligament that is pushing on to the spinal cord, and suctioning it out.  The incision is about 5mm long, about the width of a baby aspirin, so no stitches or staples are required. The procedure is done with local anesthesia and IV sedation, not full anesthesia, which makes recovery time quicker. After the procedure, patients are able to walk out of the hospital, no bed-bound recovery.  Risks of the procedure include infection and increased bleeding, but the complication rate is very rare, and the procedure has been demonstrated to be as safe as epidural steroid injections.

There are many therapies for back pain that help relieve the symptoms, and improve functionality, but are not correcting the problem itself.  There are many surgeries to correct the problem, but they can involve high risk, and lengthy recovery times. The MILD procedure is a way to correct the issue causing the pain, without the difficulties associated with an invasive spinal surgery.  

References:

Deer TR, Mekahil N, Lopez G, Amirdelfan Kasra. (2010), Minimally Invasive Lumbar Decompression for Spinal Stenosis. The Evolving Treatment of Pain, 1(S1): 29-32

Mekhail, Nagy, et al. (2012), Functional and Patient-Reported Outcomes in Symptomatic Lumbar Spinal Stenosis Following Percutaneous Decompression. Pain Practice, 12(6): 417–425. doi: 10.1111/j.1533-2500.2012.00565.x

Staats PS, Chafin TB, Golovac S, Kim CK, Li S, Richardson WB, Vallejo R, Wahezi SE, Washabaugh EP, Benyamin RM, MiDAS ENCORE Investigators. Long-term safety and efficacy of minimally invasive lumbar decompression procedure for the treatment of lumbar spinal stenosis with neurogenic claudication: 2-year results of MiDAS ENCORE. Reg Anesth Pain Med. 2018;43:789-794.

Superfood: Beet & Orange Salad with Grilled Trout + Walnuts

Ingredients:

  • 12 oz. Boneless Skinless Trout
  • 10 oz. (about 2) Red Beets
  • 6 cups Arugula Lettuce Leaf
  • 2 oz. Goat Cheese
  • 8 Tbsp Walnut Halves & Pieces, Chopped
  • 1/2 cup Tarragon, Chopped
  • 2 ea Orange Segments
  • 1/2 cup Balsamic Vinaigrette

Method:

  1. Preheat a char-grill or grill pan. Spray with oil to help stop the trout from sticking. Grill the trout until the internal temperature reaches 145F degrees, about 2-3 minutes on each side. Set aside.
  2. Peel and section oranges and set aside. Roast or boil whole beets until cooked through and tender, about 45-60 minutes depending on size. Chill then peel skin and dice. Set aside. Toast walnuts until golden brown and fragrant. Set aside.
  3. For each salad: Toss together 1/2 cup orange sections, 1 1/2 cup lettuce, 1/2 oz. crumbled goat cheese, 1/2 oz. (2 Tbsp.) walnuts, 3 oz. cooked trout, 2 Tbsp tarragon and to Tbsp dressing. Plate the salad.
  4. In the empty bowl, add the beets and toss lightly with leftover dressing. Place beets on the salad last (this will prevent everything from turning red).

Nutrition Facts:

  • Calories: 420
  • Total Fat: 30g
  • Saturated Fat: 5g
  • Total Carb: 15g
  • Protein: 25g
  • Dietary Fiber: 4g
  • Sodium: 380mg



Superfood: Grilled Salmon with Orange Grapefruit Caprese

Ingredients:

  • 4 ea Wild Salmon Filet, 4 oz.
  • 1/8 tsp Fine Ground Black Pepper
  • 1/8 tsp Kosher Salt
  • 1/3 Tbsp Canola Oil
  • 4 oz. Mini Mozzarella Balls
  • 4 oz. Orange Sections
  • 2 oz. Grapefruit Sections
  • 2 Tbsp Extra Virgin Olive Oil
  • 1/8 tsp Kosher Salt
  • 1/8 tsp Black Pepper
  • 4 leaves Fresh Basil, Torn

Method:

For the Salmon:

  1. Drizzle olive oil on the salmon and season with salt and pepper. Place salmon on a pre-heated grill and cook for approximately 3 to 4 minutes on each side. Place on a baking tray and place in the oven for 5 minutes until firm but not dried out. The internal temperature should be 145F. Remove from the oven and set aside.

For the Grapefruit Salad:

  1. Use mini mozzarella balls for this recipe and cut in half. Toss mozzarella cheese, orange and grapefruit segments together and mix with olive oil, salt, freshly ground black pepper and fresh torn basil leaves.
  2. Place the grapefruit salad over the salmon and serve.

Nutrition Facts:

  • Calories: 320
  • Total Fat: 18g
  • Saturated Fat: 6g
  • Total Carb: 4g
  • Protein: 34g
  • Dietary Fiber: <1g
  • Sodium: 390mg



Superfood: Quinoa Tabouleh

Ingredients:

  • 1 cup Quinoa
  • 2 cups Water
  • 1 ea Small Tomatoes, Fresh, Diced 1/4″
  • 1/2 cup Peeled Cucumbers, Seeded and Diced
  • 1 cup Fresh Italian Parsley, Chopped
  • 2 Tbsp Fresh Mint Bunch, Chopped
  • 1 Tbsp, 1 1/2 tsp Lemon Juice, Fresh
  • 1/2 cup Green Onions, Thinly Sliced
  • 1/4 tsp Salt
  • 1/4 tsp Fine Ground Black Pepper
  • 1/4 cup Canola Oil

Method:

  1. Place quinoa in a pot with water and bring to a boil; lower heat to simmer and cook until tender and outer ring is visible, about 15 – 20 minutes. Drain and chill.
  2. Add the tomatoes, cucumber, parsley, mint, fresh lemon juice and scallions.
  3. Fold in the olive oil to separate the grains. Season with salt and pepper.

Nutrition Facts:

  • Calories: 260
  • Total Fat: 16g
  • Saturated Fat: 1.5g
  • Total Carb: 25g
  • Protein: 6g
  • Dietary Fiber: 4g
  • Sodium: 130mg

Got Pain? Why You Should Try Acupuncture

  • Knee Pain

For many of us, who suffer from injuries or pain, we eventually seek medical help.  According to recent surveys, 80% of Americans will suffer from some pain at some point.  Many of these folks, suffer from chronic pain- defined as pain that has persisted for more than 3 months. Current options to manage pain include a myriad of options from physical therapy, dry needling, anti inflammatory medicines and as a last resort opioids. Given the recent opioid crisis, there has been a substantial push to reconsider options to manage pain.

Acupuncture has been around for thousands of years, some research even theorizing as early as 3300 BCE.  It began in China, using finely sharpened tools, and has since developed into a widely used medical practice.  It’s effectiveness has been appreciated for millenia, however, we have only recently began to understand how it actually works. It is estimated that about 2 billion people a year will get acupuncture treatments annually and it is used for a myriad of different conditions.  There have been multiple research studies, using MRIs, blood tests, and other methods, which have shown some of the amazing results acupuncture can have on a multitude of ailments.

A few studies have had patients receive acupuncture therapy, while a brain MRI was performed.  This testing showed consistent activation of different parts of the brain, which control different functions in the body, including pain perception, and mood.  For instance, studies comparing acupuncture and simple touching of the same areas (tactile stimulation), while an MRI was observing brain function, have shown that the amygdala and the hippocampus are deactivated during acupuncture, but not nearly as much during the tactile stimulation.  These two areas of the brain are activated during stress, hunger, pain, and other negative emotions. De-activating these areas will decrease the body’s perception of these negative emotions, therefore helping to manage depression, over-eating, and chronic pain.

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Acupuncture can have chemical impacts as well.  These impacts are due to the effects on neurotransmitters and endorphins, which help with mood and pain.  Acupuncture has been shown to increase the levels neurotransmitters, such as dopamine and seratonin, while decreasing noradrenaline.  Dopamine and seratonin play major roles in feelings of well-being and happiness. Noradrenaline is released during periods of stress, so decreasing the release of this neurotransmitter, can decrease the perception of stress.  Additionally, acupuncture has been shown to increase endogenous opioid peptides, or endorphins, which are the body’s natural pain relievers. These studies answer some of the questions as to how acupuncture can help with depression, anxiety, and pain.  

The Eastern medicine theory on the way acupuncture works, is due to qi (pronounced “chee”), or the body’s energy.  Qi flows through certain pathways, called meridians, and when these meridians are disrupted, the body reacts with pain.  There are twelve different meridians,
each corresponding to a different body system. The acupuncturist would follow the meridian map, according to the patient’s medical concern, and place needles in specific areas along the targeted pathway.  Doing so restores the body’s qi, and helps it flow smoothly through the meridians.

Joanna Wroblewska, MD has a quite unique perspective to this.  She is board certified in anesthesiology and pain management. On a typical day, she will treat patients with headaches, migraines, neck pain, back pain and even musculoskeletal pains such as joint pains.  With over a decade of experience, she has developed an exceptional perspective on how pain affects patients, not just physically, but emotionally, psychologically and socially.

Joanna has studied acupuncture and she integrates components of acupuncture into her daily medical practice. She acknowledges that acupuncture is not for everything or everyone, but it has a role.  When performed well, it has lasting results and can certainly supplement current
westernized approaches. She integrates acupuncture with current western treatments to treat various conditions and her patients are benefiting from this approach.

Acupuncture has various mechanisms of how it works.  The most postulated theory is that it helps stimulate your body’s own neural and hormonal systems to help create a balance within your body’s environment. Acupuncture is no longer an exotic treatment, but rather a very well accepted form of medical treatment.

Speak with our providers- Margaret Truesdell- PA-C and Joanna Wroblewska, MD to understand how acupuncture can have a lasting impression to benefit your health.  We welcome you to experience this unique combination of western medicine and acupuncture!

References

Han, J S. “Acupuncture and Endorphins.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 6 May 2004, www.ncbi.nlm.nih.gov/pubmed/15135942.

Huang, Wenjin, et al. “Characterizing Acupuncture Stimuli Using Brain Imaging …” National Institute of Health, National Center for Biotechnology Information, 9 Apr. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3322129/.

Hui, Kathleen, et al. “Acupuncture, the Limbic System, and the Anticorrelated …” National Institute of Health, National Center for Biotechnology Information, 27 Aug. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC3754836/.

Wen, Guoqiang, et al. “Effect of Acupuncture on Neurotransmitters/Modulators.” Journal of Trauma and Acute Care Surgery, Lippincott Williams and Wilkins, 5 Apr. 2016, uthealth.influuent.utsystem.edu/en/publications/effect-of-acupuncture-on-
neurotransmittersmodulators.

Wen, Guoqiang, et al. “Effect of Acupuncture on Neurotransmitters/Modulators.” Journal of Trauma and Acute Care Surgery, Lippincott Williams and Wilkins, 5 Apr. 2016, uthealth.influuent.utsystem.edu/en/publications/effect-of-acupuncture-on-
neurotransmittersmodulators.

Wen, Guoqiang, et al. “Effect of Acupuncture on Neurotransmitters/Modulators.” Journal of Trauma and Acute Care Surgery, Lippincott Williams and Wilkins, 5 Apr. 2016,
uthealth.influuent.utsystem.edu/en/publications/effect-of-acupuncture-on-
neurotransmittersmodulators.

White, A. “A Brief History of Acupuncture.” Rheumatology, vol. 43, no. 5, 2004, pp. 662–663., doi.org/10.1093/rheumatology/keg005.

Superfood: Orange & Banana Oatmeal Parfait

Ingredients:

  • 4 1/2 cups water
  • 1 1/2 cups quick oatmeal
  • 1/2 cup vanilla yogurt
  • 1 1/2 tablespoons honey
  • 1 ea medium banana, sliced
  • 2 ea orange sections
  • 1 tablespoon, 1 teaspoon grated orange peel

Method:

  1. In a medium sauce pan, bring water to rapid boil. Slowly pour oatmeal into boiling water, stirring constantly. Return to a boil. Reduce heat and simmer for 8 to 10 minutes, stirring occasionally. Remove from heat and let cool.
  2. Mix the oatmeal, yogurt and honey together. Chop the orange into small pieces. Divide the mixture into 4 bowls or jars. Top each parfait with 2-1/2 tablespoons each of banana and diced orange and 1 teaspoon orange zest. Serve cold.

Nutrition Facts:

  • Calories: 140
  • Total Fat: 2g
  • Saturated Fat: 0.5g
  • Total Carb: 29g
  • Protein: 5g
  • Dietary Fiber: 3g
  • Sodium: 35mg