Part Two: Pillow Talk

I often field the question about what is the best pillow.  I have to retrain the patient to ask a more important question: “What is the best pillow for me right now?”

Pillows are as individual as mattresses, there is no one-size-fits-all.  Patients need to figure out what pillow will likely work for them based on their body type, existing cervical spine problems, and their sleeping position.

Sleeping position: for back sleepers, the pillow needs to be thinner to avoid pushing the head in flexion and aggravating cervical spine loss of normal curve. Ideally the pillow needs to have a slight raised edge to support the cervical curve forward and a middle dip to let the back of the head cradle back (“doughnut type pillow”). Alternately, a pillow made of a material that can be molded to shape the head/neck junction can also work (feather, foam pieces).  For side sleepers, the pillow will need to be thicker to support the distance between the ear and shoulder to keep the head/neck in line with the midback.  You need to subtract the distance that your shoulder will sink into your mattress, which will depend upon the weight of your trunk and the thickness of the mattress top layer.

People alternating between back and side sleeping are the most difficult to fit with the right pillow. Usually you will need a very moldable pillow or a properly sized doughnut pillow to accommodate the position change.

Body type:  In order to account for the amount of compressive forces, larger trunks and heavier heads will need a heavier density pillow and conversely petite individuals can use a lighter density fill. Higher quality pillows will usually have at least two fill/density options (especially feather pillows).

Existing cervical spine issues: the firmness of a pillow is a very individual preference. By the time people show up in my office they have often tried several pillows and have already figured out what firmness works best for them.  As a general rule people with active inflammatory cervical degenerative issues will need a softer, more contouring material. You can still have a firmer base such as structure foam as long as you have a couple inches of softer material on the periphery. There are a variety of softer options on the market including feather, broken foam, fillable water bladders and inflatable air bladders. The latter two options are less common but some patient enjoy the flexibility of modifying the thickness and firmness as needed.

Also remember that pillows have a relatively short life span, and usually need to be replaced every couple of years.

Sleep and Chiropractic

Sleep disruption is a pretty epidemic complaint and a topic of many questions at the office. It is a broad topic but I thought it would at least be worth highlighting some of the issues between common presenting complaint and sleep.

When patients experience pain related sleep disruption, I first have to try to understand if the problem lies with the sleep set up (bed, pillow, sleeping position), or if it is related to their intrinsic presenting neuromusculoskeletal issues. You can normally distinguish between the two by asking a few questions:

-          Have you always had issues with disrupted sleep or did this recently or suddenly start?  Did you have a new injury or problem before you started experiencing sleep disruption? 

-          Have you had any changes in bedding, mattress, pillows in the last three months?  How old is your mattress? 

-          Do you sleep better or worse when you are not sleeping in your normal bed, such as when traveling? This question is often one that will be a big clue. If patients have the same symptoms regardless of the place where they sleep, you lean toward and intrinsic issue with their body, but if they sleep better when away from home, you start to wonder about the adequacy of their current sleep set up.

Distinguishing between a problem with the sleep set up versus the patient’s intrinsic issues and loss of tolerance to a normal bed/pillow combination is important so that you do not waste resources chasing the wrong solution.

BASIC ANTI-INFLAMMATORY PROTOCOL FOR ACUTE INJURIES

BASIC ANTI-INFLAMMATORY PROTOCOL FOR ACUTE INJURIES

As many of you know, we will often use supportive supplementation for acute injury management as well as more chronic inflammatory soft tissue management. I have gotten several requests to post the basic protocol, so here it is.

The protocol addresses three major biochemical pathways of inflammation response: vit D active metabolites, essential fatty acid cascade and the botanicals.

One important caveat: while generally safe, there are some contraindications to usage, especially in patients on any anticoagulant therapies. The dosage will also need to be adjusted a bit depending upon the acute or chronic state, and if patients are already taking some vit D as part of a calcium supplement or a multivitamin

·       Vit D3 5000 IUs

·       Fish oil with high EPA/DHA content: 2-3 grams/day

·       High grade botanical curcumin or curcumin/ Boswellia combo.  The curcumin should be at 95% concentration and the minimal dosage is 2 gr/day for 7 days in acute severe presentations ( acute disc herniation for example), 1-2 grams a day for long term presentations ( chronic inflammatory lumbar disc degeneration)

Cervical disc degeneration and smoking

I had an “interesting” conversation with a patient yesterday. We were reviewing the gentleman’s cervical X-rays and the rather surprising amount of cervical disc degeneration it showed, out of line with his age and the amount of trauma he could recall. When reviewing all risk factors for cervical degenerative disc disease, I pointed out that smoking is a big risk factors, up to 4 times the incidence versus non-smokers. Somehow that piece of information did not sit well with the gent in question, who smokes well over a pack a day and seems quite in denial about the ill effects of his habit. However, science talks louder than our denial and I forwarded him this piece of research, to let him argue with the authors if he choses. And I thought it might be a good talking point for anyone else reading this blog to have on hand

https://www.sciencedaily.com/releases/2016/02/160218062227.htm

Busting sugar

New FDA food labeling rules went into effect in July of 2018. When discussing nutrition with patients, I don't spend a lot of time on the food labeling portion since it only tells a small part of the story.  Most foods that we should be eating should not present in a labeled package anyway, and other variables such as source of product, ingredient list and overall nutrient density are probably more important.

I do however welcome this new labeling rule because it finally exposes a great villain that has been living below most of our radars for too long: sugar. Some foods have inherently more sugar than others in their naturally occurring forms ( fruit for example), and while the total amount of sugar we consume matters, the quality of our sugar intake also matters. A fruit will contain a variety of other nutrients that will slow the absorption of sugar and participate in the proper conversion of sugar to energy, while plain added refined sugar does not.

The new labeling law breaks down sugar into total sugar and added sugar and the latter can be very enlightening. I recently sat down with a gentleman who was living off granola bars, assuming those were healthy meal replacement options. His favorite bar contained a whopping 15 grams of added sugar ( not even counting a total 37 gr of carbs from mostly refined grain flour).  I ultimately had to convince him to switch to more whole food options such as plain nuts, fruit, boiled eggs etc... but we were also able to find some nut/fruit bars that had less than 5 grams of added sugar and were still palatable to him when grabbing something on the go.

The current recommendation is for less than 50 grams of added sugar per day. I would say that optimally that is even high and we should aim closer to 30-40 grams. But considering that most US adult get around 150 on average right now, I would be satisfied with just 50 grams

https://www.npr.org/sections/thesalt/2016/05/20/478837157/the-added-sugar-label-is-coming-to-a-packaged-food-near-you

SURVIVING YOUR COMPUTER: WHY SIT WHEN YOU CAN STAND ?

When it comes to the design of the human body, you can argue back and forth quite a bit about what the body is engineered to do optimally and what it is not ( that is the case in the area of human nutrition for example). One area where there is very little controversy is the area of sitting. The human body is clearly not engineered to sit for very long. Not just for the musculoskeletal system, but also for the cardiovascular system and the central nervous system. A while back I uploaded to the blog a longitudinal study on the mortality rate associated with the number of hours the average adult spent sitting during their day.  The results were not pretty. 4 hours of total sitting seemed to be the upper end of what the body could take before the health outcomes fell off a cliff. Back pain was the least of their problems in the end, while rates of strokes and dementia went up steeply.

Thankfully, furniture design has come to the rescue of the majority of the US adults who derive an income from working full time at a desk/phone/computer.  And the good news is that there is a big range of retrofit options at a variety of price points. Some are as simple as a desk stand to perch a laptop. Intermediate options include a sit-stand telescoping platform that sits on your desk but does not require any hardwired installation. The upper echelon of sit stand workstations can hold multiple monitors and electrically adjustable height. 

The HR policies about employees requesting and receiving adjustable workstations still vary a lot.  Some will do it simply upon employee request for accommodations, while other still request cumbersome medical notes and a lot of paperwork. Most employers do have a policy for that particular situation, and the HR department is the place to contact.

 For an idea of what may be available out there, this article is a good starting point. As you begin using a sit stand station, increase your standing time gradually, and aim for a total of no more than 4 hours of sitting per day. Also remember that you will need to bring with you shoes that are compatible with standing.

https://www.omnicoreagency.com/best-standing-desks/

T'IS GARDENING SEASON AGAIN

With the first nice weekend of the planting season, gardeners always seem to go overboard. And so it was no surprise to see the first wave of gardening strains flow through the office this week.

Enough people have asked me that same question since Monday that I might as well re-post that answer for a broader audience. The question : " what is that gardening-thingy-rocking-stool you recommended last year so that I don't have to bend over my flower garden for hours?"

https://www.amazon.com/Vertex-GB1200-Garden-Rocker-Gardening/dp/B0002P12FA

There are several variants of that same model you can purchase at your local garden store or online. For those of you who grew up in dairy country like I did, you will note one major flaw: it really needs a strap on belt system so that you can tie it to your rear like a milking stool and not have to pick it up every time you move down a row of plants. One of my patients talked her husband into doing just that, and the result was quite spectacular.  So if you are handy, or have a handy living mate, think about retrofitting that. The rest of us will have to wait until the manufacturers make that improvement

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HEARING LOSS AND DEMENTIA

During my first year in practice, many moons ago, I encountered an unexpected issue with my patients that had nothing to do with my skills or their presenting problems: many of them could not hear me well. I blamed some of it on my remaining accent my tendency to speak fast and mumble, but I also noticed a pattern among those complaining that my voice was too soft: they were disproportionately older and males.

Out of puzzlement and frustration I consulted with an audiologist that I knew. She took some measurements of my voice and analyzed volume and pitch. It turns out that my voice was of normal volume for my gender and size, however my pitch was in a narrow range of auditory frequencies that are lost first in age related hearing loss ( especially in males, who tend to lose the higher pitches first). She told me that for the rest of my life, I would be the "singing canari" of early hearing loss: I would be one of the first person that someone would stop being able to hear.

Her prophetic words have, for better or for worse, turned out to be very true. 

Last year, I decided to turn my soprano monotone voice from a problem into an opportunity. I was doing some research on the long term environmental and modifiable risk factors for dementia when I stumbled upon a landmark, large scale meta-analysis from 2016. Along with the factors that were already suspected ( hypertension, depression, diabetese, smoking etc), was a surprising newcomer: mid to later life acquired hearing loss.

The latter finding was significant in many regards. Hearing loss, it turns out, is not just an annoyance. We already knew it carried a safety risk for the person affected as well as those around them since emergency signals cannot not be heard. Most profoundly and more commonly however, hearing loss is associated with some definite decline in cognitive function over time. It makes sense if you understand how various lobes of the brain interact and provide stimulus for each other. If one of the five senses goes down, that is an enormous amount of normal daily stimulus that is lost as a domino effect to parts of the brains responsible for normal processing and storing of information.

The good news about hearing loss is that it is in many cases correctable with a well fitted hearing aid, thus making hearing loss a dementia risk factor that can be averted ( unlike other risk factors that are more difficult to control). Hearing aid technology has a way to go yet, and the price tag is not very friendly, but if you understand the consequences of not addressing hearing loss, it is still worth the effort and resources.

So back to my little soprano voice and the gents who grumble about it in my treatment room. I now take time to let people know that they are probably experiencing early hearing loss and this is a wonderful opportunity to intervene early.  Some of those folks are ill disposed toward the messenger of unpleasant news, but I am finding out that good science and the specter of everyone's worst aging nightmare is still a powerful motivator to maybe do something about it. 

https://www.alz.org/aaic/releases_2017/AAIC17-Mon-briefing-risk-factor.asp