Troubled by a neck pain? You’re not alone. A 2017 population-based study determined the prevalence of neck pain in a population of adults aged 20 and above was 20.3% or 1 in 5 people. Although a variety of risk factors for neck pain have been identified, including your posture/positioning while at work, one risk factor that isn’t often talked about how you position yourself when you sleep. A study published in the Journal of Physical Therapy Science on June 29, 2017, was specifically aimed at identifying the effects of sleep posture on neck muscle activity.
The authors found that the activity of the affected muscles was significantly different in each of the three main sleeping positions: supine with both hands at the side (BHS), supine with both hands on the chest (BHC), and supine with the dominant hand on the forehead (DHF). The authors concluded that
“sleep posture is important and prevents neck and shoulder musculoskeletal pain.”
8 Ways to Relieve Neck Pain from Sleeping in the Wrong Position
Based on these findings and other research detailed below, here are 7 ways to relieve neck pain from sleeping in the wrong position:
1. Don’t sleep in the supine DHF position
If you’re one of those people who put one hand on their forehead while sleeping, you’re may be contributing to your neck pain. When you sleep in this posture, the upper trapezius and scalene muscles are activated on one side. The imbalanced activation of the muscles causes a rotation in the neck, and that leaves you with a misalignment of the cervical spine.
2. Avoid the supine BHC position
The supine BHC position is more symmetrical than the DHF since you have positioned both hands on the chest while lying on your back. The difference in the activity between the scalene and upper trapezius muscles is lower. Still, this position of the arms causes some level of tightness of the upper trapezius, which can cause numbness and neck pain.
3. Get used to the BHS position
The researcher found that the difference in muscle activity was the smallest in the supine BHS (both hands at the side) position. When you go to a relaxation course, they tell you to lay in the so-called Savasana or corpse pose. You lay on your back, with the legs slightly separated and both arms relaxed by the side. The head is in a straight continuation of the neck, without falling to either side. It’s a balanced position, and it turns out it’s the best posture for sleep.
4. Your pillow makes a difference
The pillow you use affects the shape of the cervical spine. With that, the pillow has a direct effect on muscle fatigue and pain in that area. A study from 1997 made a comparison of three types of pillow: the usual pillow, a roll pillow, and a water-based pillow. They found that the water-based pillow not only improved the quality of sleep but also led to pain relief and reduced intensity of neck pain in the morning. Although this study is not fully reliable because it doesn’t take body position into account, most people would probably agree that sleeping on the right pillow can make a big difference.
5. Use a pillow with an adaptable shape
The most important thing to look for in a pillow is flexibility. When you put your head on it, it should change its shape to perfectly support your neck. When you change your position, the shape of the pillow should change also. If you don’t like a water-based pillow, you can opt for a more traditional choice. Feather pillows are good in terms of conforming to the neck’s shape, however, they tend to collapse with continued use so it’s important to change them once per year. A high-quality memory foam pillow is another good choice. It will last longer and continue to conform to the shape of your head and neck.
6. Do something About that insomnia
If you suffer from both insomnia and neck pain, you may be interested to learn that there is apparently a reciprocal relationship between these two factors:
Neck pain can interfere with sleep and insomnia heightens your perception of pain the next morning.
If you’re waking up with stiffness in your neck and the entire body, morning stretches can help. Gentle Hatha yoga, for example, will improve the mobility of all muscles and joints and will make you feel relaxed. A randomized-controlled trial identified the effects of home-based yoga practice for chronic neck pain. The participants who practiced yoga reported significantly less neck pain when compared to the participants who did another type of exercise. Yoga seemed to influence the functional status of the muscles in the neck area as it improved the physiological measures of neck pain.
8. Consider acupuncture
If you suffer from chronic neck pain that doesn’t go away no matter how much you try to improve your sleeping position or the pillow, perhaps it’s time to consider acupuncture which can be an effective treatment for cervical pain. A controlled trial showed that relevant acupuncture treatment combined with heat resulted in a reduction in neck pain.
The Bottom Line
There’s no doubt that neck pain causes a huge amount of discomfort. When you wake up with stiffness and pain, your entire day can be impacted by how you feel. But remember that you do have options to make the pain go away or at least reduce it to a significant degree. Hopefully, the eight methods suggested above will help.
If you have tried something that worked for you and is not on this list, please share it in the comment section below.
There is a big wave of recent research on the oral microbiome and its relationship to systemic health. In this article, we will focus on links between the oral microbiome and the autoimmune disorders, Sjogren’s Syndrome, Lupus, and Rheumatoid Arthritis.
Dysbiosis (an out-of-balance ecosystem of commensal and pathogenic bacteria living in the oral cavity) may be a key factor in a variety of disorders. This includes not only obvious ones like dental caries and periodontal disease, but also systemic illnesses, like cardiovascular disease, chronic obstructive pulmonary disease (COPD), and maybe even cancer (1)(2)(3). This growing body of research offers us a more ecological and holistic understanding of the role of the oral microbiome. It also begs the question:
What other diseases could be triggered by oral dysbiosis?
To answer this question, we first look at autoimmune diseases.
What is An Autoimmune Disease?
An autoimmune disease is a disorder in which a body’s immune system mistakenly attacks its own healthy cells. For example, in multiple sclerosis, the current understanding is that the patient’s own immune system T-cells mistakenly attack myelin cells that make up the tissue that sheathes motor nerves (axons). This, in turn, triggers a cascade of inflammation that damages not only the myelin sheath but also the cells that produce myelin and the axons themselves. The result is a loss of motor control and even paralysis. Why these people’s T-cells go haywire is not yet fully understood, although genetic susceptibility triggered by viral and other environmental insults (e.g., smoking) is likely.
The classic understanding is that, in these cases, the immune system mistakes a normal protein on its own cells for a foreign antigen and mounts a response against the cells displaying such auto-antigenic triggers. We still have an incomplete picture of how the immune system learns to differentiate its own cells from foreign molecules and how both genetic susceptibility and environmental factors can trigger this self-destructive immune response.
New insights into immune disorders place autoimmune diseases in a larger category of immune-mediated inflammatory diseases (IMID). IMID’s are conditions which result from any abnormal activity of the body’s immune system, from allergic reactions to diabetes. Autoimmune diseases are a subset of IMIDs. They are defined as disorders in which the immune system reacts specifically against its own cells and tissues as if they were pathogens or infected cells. Researchers have also recently developed another sub-category of autoinflammatory diseases…but we’ll leave the specifics of those disorders to another post.
The last few years have seen an increase in awareness of autoimmune diseases as well as a new focus on providing better care and more health solutions for the millions suffering from these disorders. To this end, researchers have been investigating potential causes and associated risk factors that increase individual susceptibility to autoimmune disorders. One of the newest research efforts explores the relationships between the oral microbiome and systemic diseases with a special focus on systemic autoimmune diseases.
The Oral Microbiome-Systemic Disease Connection
The new understanding of the oral microbiome is shaping how we think about dental caries, periodontal and systemic diseases. While the traditional view held that these diseases were caused by a small number of pathogens, we now consider the oral microbiome to be a finely tuned ecosystem, a balanced (or unbalanced) community of microorganisms that mediates not only oral health and disease but also some systemic diseases (5).
So far, three pathways that link oral infections to secondary systemic effects have been proposed:
Metastatic Infection: Transient bacteria from oral infection or dental procedures can gain entrance into the blood and circulate throughout the body. Such disseminated microorganisms may find favorable conditions, settle at a given site where they may multiply, colonize, and infect.
Metastatic Injury: Certain bacteria can produce toxins that, when excreted or introduced into a host body, trigger tissue damage, an immune response or produce other pathological manifestations.
Metastatic Inflammation: Soluble molecules that enter the bloodstream may react with circulating antibodies to produce large complexes that give rise to acute and chronic inflammatory reactions. (6)
A number of autoimmune diseases have been linked to multiple pathogenic factors, including genetic susceptibilities, environmental triggers, and dysregulated immune responses. Dysregulated immune responses may involve over-activated B-cells stimulated by toll-like receptors (TLRs). TLRs are one of a larger category of pattern recognition receptors (PRRs). PPRs have evolved to detect proteins on or secreted by pathogens. They have also been implicated in the production of autoantibodies to nuclear and cytoplasmic autoantigens and the presence of anti‐citrullinated protein antibodies (ACPA) (7)(8). Such dysregulated immune responses can trigger progressive inflammation of certain tissues that manifests in particular autoimmune diseases such as Sjogren’s Syndrome, Systemic Lupus Erythematosus, and Rheumatoid Arthritis.
Common Oral Symptom: Extremely Dry Mouth
Sjogren’s Syndrome is an autoimmune disease that mainly affects the lachrymal (tear) and salivary glands. Thus, common symptoms include dry eyes and a significant decrease in saliva production that can cause difficulty in speaking, eating, and swallowing. Saliva is an important component in the composition of the oral microbiome due to its role in protein precipitation and biofilm formation. Insufficient saliva is associated with high bacterial species counts, as well as the frequent occurrence of caries.
In this disease, cytokines and lymphocytic infiltrates in exocrine glands cause damage that reduces secretion. Activated B-cells and T-cells stimulated by TLRs produce increased levels of inflammatory cytokines, IFN-𝛾 and IL-17, that disrupt epithelial cells in the salivary and lacrimal glands, inhibiting their production of saliva or tears and altering the mucin content. (9).
Systemic Lupus Erythematosus (SLE)
Common Oral Symptom: Lichenoid Lesions, Lupus Cheilitis
SLE is a complex, multifactorial connective-tissue disease that commonly affects joints and many organ systems including the skin, joints, heart, lungs, kidneys, and nervous system (10). The disease is characterized by the presence of autoantibodies to nuclear and cytoplasmic autoantigens.
Oral symptoms of SLE include lichenoid lesions and lupus cheilitis. Lichenoid lesions resemble a white spider web or film on the inner cheeks, tongue, and roof of the mouth. Lupus cheilitis may appear as a rash on or swelling of the upper and lower lips, sometimes including the surrounding areas of the mouth.
So far there are a couple of proposed mechanisms that link the oral microbiome to SLE. The first suggests that certain viral infections of the mouth, such as the Epstein-Barr Virus (EBV, the pathogen that causes mononucleosis, aka mono) are implicated in SLE pathogenesis. Certain EBV antigens have structural and functional molecular similarities to SLE autoantigens. Impaired EBV-specific T-cell responses in genetically susceptible individuals may trigger autoantibody responses to self-cellular antigens (11). In other words, EBV antigens share molecular similarities to SLE antigens and other cellular components, causing the cells of our acquired immune system–normally the defenders of the body–to mistakenly attack cells free of viral infection.
Another proposed mechanism that links SLE to oral microbiomes is based on recent research that organisms in the blood (blood microbiome) are associated with a number of non-communicable chronic diseases. Although the gut microbiome is the main site of origin for pathogenic microbes that infiltrate the blood, the oral cavity is another source for translocated microbes (12). A high dormant blood microbiome (i.e., the presence of detectable, but not culturable, microbes) is associated with chronic inflammatory diseases, including SLE.
Common Oral Symptom: Presence or Early Onset of Periodontal Disease
Rheumatoid Arthritis is a well-known disease (not to be confused with osteoarthritis, which is not considered autoimmune). Many people are unaware that it is categorized as an autoimmune disease, the abnormal immune reaction triggering inflammation that causes the tissue lining inside of joints to thicken. Not only joints may be affected, but also other tissues, including the valves of the heart. At the molecular level, the presence of autoantibodies, like anti‐citrullinated protein antibodies (ACPAs) contributes to a loss of immune tolerance to self-antigens and is one of the first steps toward inflammation (7).
“ACPAs appear up to 10 years before the onset of clinical manifestations of rheumatoid arthritis…The presence of ACPA predicts the evolution to rheumatoid arthritis” (13)(14)
ACPAs are a group of autoantibodies found in 50-70% of RA patients, but infrequently associated with other diseases or found in healthy individuals, making them uniquely predictive factors for disease pathogenesis. The presence of ACPAs, along with the maturation of ACPA response mechanisms, are associated with the prodrome of the disease that precedes the onset of clinically apparent RA. This preclinical RA is an entire subset of the disease itself, and has been broadly defined and broken down into six phases by the European League Against Rheumatism (EULAR).
What’s also interesting about ACPAs is that they are associated with periodontal infection with P. gingivalis, suggesting that periodontitis could be a significant risk factor for RA. Periodontal disease refers to inflammatory processes in the tissues surrounding the teeth (gums, etc.) in response to bacterial accumulations, or dental plaque, on the teeth (15). Although it originates in the mouth, it has been linked to systemic diseases–more information can be found here. The image below illustrates in further detail a step-wise process of how periodontal disease can lead to chronic inflammation in rheumatoid arthritis.
Autoimmune disease is an umbrella term for more than 100 different illnesses, each presenting a variable array of symptoms. Due to the variability of symptoms and a history of disease definition by body part (joints, nerves, skin) which does not reflect our current understanding of the systemic nature of the immune system, these diseases have been difficult to diagnose and treat.
Recognizing similarities between autoimmune diseases will provide more insight into the pathophysiological processes deranging the immune response.
This will help us understand the interactions of genetic susceptibility and environmental triggers that lead to these disorders.
The mounting research on the oral microbiome and its connection to systemic autoimmune diseases is exciting. Not only could the detection of imbalances in the microbial composition facilitate the early diagnosis of autoimmune diseases, but also correcting these microbial imbalances may have potential as a treatment for autoimmune diseases.
Bingham, Clifton O., and Malini Moni. “Periodontal Disease and Rheumatoid Arthritis: the Evidence Accumulates for Complex Pathobiologic Interactions.” Current Opinion in Rheumatology, vol. 25, no. 3, 2013, pp. 345–353., doi:10.1097/BOR.0b013e32835fb8ec.
Ramesh, Asha, et al. “Chronic Obstructive Pulmonary Disease and Periodontitis – Unwinding Their Linking Mechanisms.” Journal of Oral Biosciences, vol. 58, no. 1, 2016, pp. 23–26., doi:10.1016/j.job.2015.09.001.
Heikkilä, Pia, et al. “Periodontitis and Cancer Mortality: Register‐Based Cohort Study of 68,273 Adults in 10‐Year Follow‐Up.” International Journal of Cancer, vol. 142, no. 11, 11 Jan. 2018, pp. 2244–2253., doi:10.1002/ijc.31254.
Smith, D A, and D R Germolec. “Introduction to Immunology and Autoimmunity.” Environmental Health Perspectives, vol. 107, no. Suppl 5, Jan. 1999, pp. 661–665., doi:10.1289/ehp.99107s5661.
Zhang, Xuan, et al. “The Oral and Gut Microbiomes Are Perturbed in Rheumatoid Arthritis and Partly Normalized after Treatment.” Nature Medicine, vol. 21, no. 8, 2015, pp. 895–905., doi:10.1038/nm.3914.
Babu, Nchaitanya, and Andreajoan Gomes. “Systemic Manifestations of Oral Diseases.” Journal of Oral and Maxillofacial Pathology, vol. 15, no. 2, 2011, pp. 144–147., doi:10.4103/0973-029x.84477.
Nikitakis, Ng, et al. “The Autoimmunity-Oral Microbiome Connection.” Oral Diseases, vol. 23, no. 7, 2016, pp. 828–839., doi:10.1111/odi.12589.
Browne, Edward P. “Regulation of B-Cell Responses by Toll-like Receptors.” Immunology, vol. 136, no. 4, Feb. 2012, pp. 370–379., doi:10.1111/j.1365-2567.2012.03587.x.
Gonzales, S, et al. “Oral Manifestations and Their Treatment in Sjogren′s Syndrome.” Oral Diseases, vol. 5, pp. 153–161., doi:10.1111/odi.12105.
Kuhn, Annegret, et al. “The Diagnosis and Treatment of Systemic Lupus Erythematosus.” Deutsches Ärzteblatt, vol. 112, no. 25, 19 June 2015, pp. 423–432., doi:10.3238/arztebl.2015.0423.
Draborg, Anette Holck, et al. “Epstein-Barr Virus and Systemic Lupus Erythematosus.” Clinical and Developmental Immunology, vol. 2012, 2012, pp. 1–10., doi:10.1155/2012/370516.
Potgieter, Marnie, et al. “The Dormant Blood Microbiome in Chronic, Inflammatory Diseases.” FEMS Microbiology Reviews, vol. 39, no. 4, 4 May 2015, pp. 567–591., doi:10.1093/femsre/fuv013.
Willemze, Annemiek, et al. “The Influence of ACPA Status and Characteristics on the Course of RA.” Nature Reviews Rheumatology, vol. 8, no. 3, 2012, pp. 144–152., doi:10.1038/nrrheum.2011.204.
Arkema, Elizabeth V, et al. “Anti-Citrullinated Peptide Autoantibodies, Human Leukocyte Antigen Shared Epitope and Risk of Future Rheumatoid Arthritis: a Nested Case–Control Study.” Arthritis Research & Therapy, vol. 15, no. 5, 2013, doi:10.1186/ar4342.
Bingham, Clifton O., and Malini Moni. “Periodontal Disease and Rheumatoid Arthritis.” Current Opinion in Rheumatology: the Evidence Accumulates for Complex Pathobiologic Interactions, vol. 25, no. 3, May 2013, pp. 345–353., doi:10.1097/bor.0b013e32835fb8ec.
A new law in Connecticut, effective July 1, 2018, will allow healthcare providers to prescribe controlled substances for mental health and substance abuse treatment via telemedicine. S.B. 302 essentially reverses the state’s restrictions on the prescription of Schedule 1, 2, and 3 controlled substance via telemedicine tech, though opioids don’t seem to be included.
With this new bill, Connecticut joins a select group of states looking to utilize digital health tools and technology in a more meaningful way. This represents the beginning of a rising tide, and while it’s looking good on the state level, federal law still has to catch up. At least, according to some, there’s still hope.
“The nation’s ongoing opioid abuse crisis is creating a groundswell of support for changes in federal law to make telemedicine and telehealth a more prominent feature in treatment,” writes Eric Wicklund for mHealth Intelligence. “Congress is currently considering several bills that would, if passed, create a special registration through the U.S. Drug Enforcement Agency to enable healthcare providers to prescribe controlled substances through telemedicine.”
This support for telemedicine has been growing steadily as it’s proven itself to be one of the major emerging technologies in healthcare — but before we get too far, let’s back up for a moment. What exactly is telemedicine, what other obstacles does telemedicine face, and why is it that experts are calling it “the future of healthcare”?
What Is Telemedicine?
Penn Medicine associate CIO John Donohue, writing for Healthcare IT News in 2016, asks, since telemedicine has been around now for “almost twenty years … why is it not as common as sliced bread?” The answers to that are many, but perhaps one is that the public isn’t entirely sure just what “telemedicine” is — but that’s changing quickly.
“People too ill to attend a clinic, without adequate transportation, or without time to spare can turn to their mobile device and video conference with a trained health care practitioner through apps such as Doctor on Demand and NowClinic,” they write.
This description of “mHealth” matches the definition of telemedicine. If we were to take the cut-and-dry, no-funny-business definition offered by Community Impact News, then “telemedicine is the provision of healthcare services to a patient by a doctor in a remote location using technology.”
The first serious portrayal of telemedicine came from Hugo Gernsback, according to Smithsonian Magazine, in 1925 via a device called a ‘teledactyl’ which would “allow doctors to not only see their patients through a viewscreen, but also touch them from miles away with spindly robot arms.”
Since then, fiction and fantasy have become fact and reality. Many modern societies now operate with bandwidth and infrastructure that support telecommunication technology on a day-to-day basis. Apps like FaceTime and Skype, in conjunction with the prevalence of the modern day phone, of course, have made remote face-to-face interactions not only possible but commonplace and expected.
This has fueled the recent growth in telemedicine and mHealth. George Washington University actually predicts that the global homecare diagnostics and monitoring market will grow 8.71 percent between 2016 and 2020. This growth is not based solely on expectations and convenience — there are concrete benefits to the deployment of telemedicine.
Healthcare cost savings: “Reducing or containing the cost of healthcare is one of the most important reasons for funding and adopting telehealth technologies,” writes the ATA. Telemedicine can help to save money in healthcare by increasing efficiency via reduced travel times, fewer or shorter hospital stays, and by further automating administrative roles and responsibilities, which make up 31 percent of employees in the average physician’s office.
Better quality care: Telemedicine improves quality of care by making it easier to for providers to follow-up with patients, as well as to monitor patients remotely, and respond to queries when called upon. “In some specialties, particularly in mental health and ICU care, telemedicine delivers a superior product, with greater outcomes and patient satisfaction,” the ATA writes.
Better access, more consistent engagement: The eVisit website makes brilliant points about access to niche medical specialists, stating that telemedicine “makes it easy for primary care doctors to consult medical specialists on a patient case, and for patients to see a needed specialist on a rare form of cancer, no matter their location.” Ease of access will inevitably lead to more consistent engagement, meaning more “more questions asked and answered, a stronger doctor-patient relationship, and patients who feel empowered to manage their care,” they write
Patient demand and satisfaction: You can’t discount patient demand, and a world without telemedicine is becoming a world of the past. “Over the past 15 years, study after study has documented patient satisfaction and support for telemedical services. Such services offer patients the access to providers that might not be available otherwise, as well as medical services without the need to travel long distances,” writes the ATA.
Unfortunately, for all the benefits and applications of telemedicine, the technology isn’t perfect yet.
The Cons of Telemedicine
When asked, “what are the major limitations and barriers to a full-blown rollout of telemedicine across the country?,” CIO John Donahue responded to Healthcare IT News:
“A fistful of issues prevents us from fully realizing the potential of telemedicine. The largest, of course, is reimbursement. Bending the cost curve in healthcare is going to require the reduced costs typically associated with telemedicine programs. Limited reimbursement in today’s market has been a constraint. This is improving over time and as the value associated with telemedicine becomes more tangible, the constraint should be less of an issue. Clinical and legal concerns are also potential issues, but healthcare organizations have been working with the appropriate local, state and federal agencies to develop workable solutions to alleviate these concerns.”
While the cost may be a huge issue, it’s one that even Donahue admits is improving. His analysis that legal concerns are issues is one that’s shared by the experts at Vsee.
“Because technology is growing at such a fast pace, it’s been difficult for policymakers to keep up with the industry,” they write. “There is great uncertainty regarding matters like reimbursement policies, privacy protection, and healthcare laws. In addition, telemedicine laws are different in every state.”
Still, even larger than any other concern has to be cybersecurity and, in effect, HIPAA compliance. This doesn’t refer to just the legislation surrounding HIPAA compliance but the actual problem of poor cybersecurity and data breaches.
“As information has increasingly been stored on digital platforms it has increased in volume as well … a shift has occurred because criminals have access to more data, data that can be taken in essentially a single sweep,” writes Chloe Moore with Fiscal Tiger. “The scope of data breaches almost can’t be overstated. There is no entity that has escaped the reach of cyber-criminals. From credit reporting bureaus to the government, and from phone numbers to social security numbers, hackers seem to be able to infiltrate and steal it all.”
The more connections that pop up, tying the internet of things (IoT) to the field of healthcare, the more opportunities cybercriminals will have to steal personal and private information. In turn, this means the potential for massively debilitating HIPAA violations that, at this point, there currently are no existing solutions to.
The Future of Healthcare
The good news is that, even though the state of cybersecurity in healthcare (and in most professional fields, honestly) is dismal, an international effort is being expended to solve the problem. The recent GDPR measures that were released to help combat data breaches lay down specific measures for international companies, including:
Pseudonymization and encryption of personal data
The ability to ensure the confidentiality, integrity, availability, and resilience of the systems and services related to the processing on a permanent basis
The ability to rapidly restore the availability of and access to personal data in the event of a physical or technical incident
A process for periodically reviewing and evaluating the effectiveness of technical and organizational measures to ensure the safety of processing
While HIPAA measures include protections, procedures, and processes that protect against data breaches, a globe that is more attuned to the issues represented by cybercrime will be better able to protect itself from them.
As time goes on, cybersecurity, policy, reimbursement, and HIPAA concerns will all be sorted out. Telemedicine isn’t ushering in these problems — they’re running rampant in our system already. It would take an astounding lack of care to create a telemedicine system that would actually exacerbate the problem to a large degree.
As such, the future of healthcare is telemedicine. The obstacles are large, but we’ll soon be over them. The benefits are too great, and the public expects it. As with every other field on the planet, technological disruption will leave its mark and rule the day.
I will be contacting everyone who has contacted me to support me. Going to find the time to do that. Never felt so alone and tired with the stresses of being a doctor in top of that. I just want to wake up one day not in dread of going to work. Nearly gave up the other day.
I might not be a marathon runner but this is my long trial. Medical training takes more than it gives