What to do if you awaken with a stiff neck

The common problem of awakening with a stiff neck is a topic that is addressed poorly, if at all, during medical training. In fact, it doesn't even have a consistent name in the medical literature. It is sometimes referred to as "torticollis” or "wry neck", but these terms also apply to more serious neurological or congential conditions.

What causes a stiff neck? The exact cause of a stiff or wry neck is sometimes never determined. It may be the result of a minor injury, a sudden jerk, or simply sleeping with the head in an awkward position. Some people believe that sleeping in a cold draft can cause this problem, although this has never been proven. The most likely source for the pain is a small swivel joint in the neck called a facet. These facet joints allow for great neck flexibility, but are also vulnerable to injury. With injury to a facet, muscle spasm develops that causes the neck to twist away from the painful side as a protective mechanism.

What can be done at home for a stiff neck? In most cases, the problem will resolve on its own in a few days to a week. There are, however, a number of measures that can help make you more comfortable or help speed up its resolution. These measures include:

1. Taking an OTC pain medication, such as Tylenol or ibuprofen.
   
   
2. Applying ice packs intermittently to the painful area during the first 24 to 48 hours of its onset. An ice massage combines the benefits of the application of cold along with massage and can help even more. This is done by freezing ice in a paper cup and massaging the painful area with the exposed ice for 10 minutes.
   
   
3. Applying heat following the use of ice can help even further. This can be done using a warm, moist towel or heating pad, or by taking a shower and directing hot water to the neck. Some experts recommend alternating between heat and cold treatments for the first few days after the onset of neck pain.
   
   
4. Gently massaging the neck muscles will help to relieve pain and encourage blood flow to the area. A topical muscle cream, such a Bengay or Icy-Hot, can be used along with massage.
   
   
5. The neck should be kept mobile by performing gentle range of motion exercises. These are done by slowly moving the chin to the chest and then the ears to each shoulder. It is best to avoid the use of a cervical collar (neck brace) and to try to return to normal activities as soon as possible.
   
   
6. Sleeping with your head on a low, firm pillow will help avoid the increased stress on the muscles and facet joints that sleeping on too many pillows can cause.
   
   
7. Activities that require a full range of motion of the neck, such as driving, should be avoided until improved.

How might you suspect a more serious problem? Rarely, awakening with stiff neck can be due to a more serious problem than the self-limited problem described above. Neck pain associated with weakness or tingling in the arm or hand could be due to a herniated (ruptured) cervical disc. Forceful trauma preceding the onset of neck stiffness may have caused serious injury to bones, ligaments, or muscles in the neck. The presence of fever along with neck stiffness is suggestive of an infection, such as meningitis, and warrants prompt medical attention.

If you have any questions about neck pain, please log into your account and send us your question. We are here to help.

Aging Skin Part III: Tips For Rejuvenation

We are now completing the third in a series about how to reduce the signs of aging in facial skin. As we have discovered, aging skin is thinner and the cells do not turn over as quickly. Dark spots may emerge in response to a lifetime of sun exposure, and wrinkles form as laugh lines and frowns deepen in the setting of collagen loss. While avoiding sun and cigarette smoke are the two most important preventive measures for younger-looking skin, genetics do play a role in how our skin ages. Since there's nothing we can do about our genes, let's take one last look at the treatments available for aging skin issues (see part II for more).

1. Stimulating collagen production

Retinol: Vitamin-A-derivative creams (such as retinol) have been clinically proven to increase the elastic collagen layer of the skin. Stronger concentrations of Vitamin A are more effective, but may have unwanted side effects of skin irritation and dryness.
Vitamin C: Vitamin C serums and vitamin supplements can be helpful in reducing the effects of photo-aging. Vitamin C is a powerful anti-oxidant that can reduce sun damage, as well as assist in collagen production.  Vitamin C is so important in skin health that a disease state, known as "scurvy" can result from lack of Vitamin C in the diet.
Lasers: dermatologists recommend different kinds of laser treatments to rejuvenate aging skin. Various wavelengths of light perform different functions. Types of lasers include (from American Board of Cosmetic Surgery):

• CO2 Lasers are generally ablative lasers used to treat scars, warts, wrinkles and other deeper skin flaws.
• Erbium Lasers can be ablative or non-ablative. They promote collagen remodeling, making them popular options for treating fine lines, wrinkles, skin laxity, and age spots.
• Pulsed-Dye Lasers are typically non-ablative lasers that heat the skin and absorb pigments to reduce redness, hyperpigmentation, broken capillaries, and rosacea.
• Fractional Lasers break up the laser energy into thousands of tiny beams to treat only a fraction of the skin in the area, which reduces downtime. Fractional lasers can be ablative or non-ablative, and are used to treat a number of age-related blemishes.
• IPL (intense pulsed light) treatments technically are not lasers, but are often used to treat similar concerns as lasers, such as sun damage, acne, rosacea, and hyperpigmentation.

2. Reducing redness

In addition to laser treatments to reduce redness, there are some medications that are effective - especially in the treatment of rosacea or adult acne:

Brimonidine gel and oxymetazoline hydrochloride cream: These prescription medications can reduce the redness caused by rosacea. They work for up to 12 hours. Once the effects wear off, the redness returns. With daily use, you can have reduced facial redness for up to 12 hours a day.

Both medications have been approved by the U.S. Food and Drug Administration (FDA) to treat the facial redness of rosacea. In clinical trials, these medications safely and effectively treated the facial redness of rosacea when used daily.

Green-tinted makeup: This cannot reduce the redness, but it can hide it. Some companies make green-tinted makeup specifically for people with rosacea.

3. Reducing dark spots

Sometimes known as "bleaching cream," hydroquinone is a prescription topical cream that slows down the pigment-making processes in the skin. Doctors usually prescribe a 4% hydroquinone cream, and a 2% version is available over the counter.

Retin-A (tretinoin) and steroids may be prescribed in addition to or in place of hydroquinone, but they might not work as well.

4. Reducing wrinkles

Botox: botulinum toxin injections temporarily paralyze facial muscles so that they no longer gather upper layers of skin into wrinkles when they contract.

Exfoliation: chemical peels and dermabrasion procedures aim to "sand off" or peel away wrinkles.
Soft Tissue Fillers (such as fat, collagen, and hyaluronic acid) can be injected  into deep wrinkles in the face to fill them in.

Face lifts: involve removing excess skin and fat in the lower face and neck and tightening the underlying muscle and connective tissue. The results typically last five to 10 years.

The bottom line is that aging is inevitable, but reducing the obvious wear-and-tear on facial skin is possible with the treatments I described in the past 2 health tips. Cosmetic dermatologists specializing in anti-aging products and procedures can be helpful in rejuvenating facial skin. Unfortunately insurance companies don't pay for cosmetic treatments, and so looking your youngest may cost a pretty penny. Only you can decide if it's worth it!

References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673383/
https://www.aad.org/public/diseases/acne-and-rosacea/rosacea/how-to-treat-the-redness
https://www.webmd.com/beauty/features/dark-spots-skin-hyperpigmentation#1
http://www.mayoclinic.org/diseases-conditions/wrinkles/diagnosis-treatment/drc-20354931

If you have any questions about skin care, please log into your account and send us your question. We are here to help.

Aging Skin Part II: Tips For Rejuvenation

For regular health tip readers, you may have noticed that I introduced a topic (anti-aging strategies for facial skin) and then never completed parts II and III. Sorry for the delay. As I was saying in my original health tip Anti-Aging Strategies For Facial Skin, Part 1  (you might want to re-read this), that our skin becomes dry, thin, inelastic, and prone to cancer as we age. There are some products and procedures that can help to slow or reverse this process to some degree.  I will organize the products by their purported effects:

1. Removing the dry, dead layer of outer skin

Our skin is constantly replacing itself, as dead skin cells slough off and fresh ones grow underneath. If you've noticed how beautiful baby skin is, that's because their cells turn over every three to five days. Compare that to turnover rates in teenage skin (about 14-21 days), middle aged skin (45-60 days) or older skin >50 years (60-90 days). No wonder our skin doesn't look baby-fresh as we age. In order to stimulate skin turnover, there are a few things we can do. Firstly, we need to remove the dry, dead layer of skin so that fresh cells can replace them. This can be achieved through mechanical (such as scrubs and rough textured surfaces - dermabrasion) or chemical means (such as acidic or enzymatic removal).

There are hundreds of different products that can help to remove dead skin cells. Over-the-counter scrubs, mitts, pumice stones, Clarisonic brushes, acid washes, and enzymatic peels are readily available. Facial skin is thinner than other parts of the body, and it's important to be gentle with it so as not to damage the deeper layers while removing the dead cells on top.

If you can afford it, I recommend seeing a skincare professional (a cosmetic dermatologist or his/her aesthetician) to optimize your anti-aging skincare regime. They can be very helpful in recommending products that have been scientifically tested, and contain prescription strength ingredients that will do the job they claim to do. Depending on your individual skin's properties (degree of oiliness or dryness, acne, wrinkles or discoloration), they can recommend a regimen that works best with your skin type.

Personally, I like to use a gentle facial exfoliation cream four times a week, with a daily alpha-hydroxy acid moisturizer. This regimen combines a mechanical exfoliation with a mild chemical peel. There are more intense skin rejuvenating procedures that are provided by dermatologists, but as far as a good basic starting regimen - try a mild mechanical and chemical combo.

2. Increasing skin cell turnover

Vitamin A products (including retinol, adapalene, and tretinoin) work by stimulating collagen synthesis in the deeper skin layers, reducing inflammation, and triggering skin turnover. They are helpful in reducing wrinkles, treating acne, and adding back some thickness and smoothness to aging skin. Over-the-counter products contain lower doses of vitamin A than their prescription counter parts, and take longer to show an effect.

Some people are more sensitive to Vitamin A products than others, and experience some redness and flakiness when they first begin using it. Retinol and vitamin A-derivative creams break down in the bright light or in the presence of acid, so it's important to apply them at night and without other creams that have salicylic, hyaluronic, glycolic or other acids in them. Because Vitamin A thins the dry, outer layer of skin, sun-sensitivity is also common. It is important to use sunscreen, especially higher SPF types, if you use Vitamin A creams regularly.

Dermatologists often say that if you only use one anti-aging product on your face, it should be a Vitamin A-derived cream. The results from retinol type creams are more pronounced than with most other interventions.

3. Hydrating the healthy skin

As we age, our skin tends to lose its moisture content as well as cell metabolism slows, hormones change, and the outer skin layer fractures. Restoring the water content to our skin is helped by avoiding harsh soaps that dry the skin further, drinking sufficient water, and applying non-comedogenic (meaning, creams that don't block pores) products to the skin surface. Facial moisturizer creams that are generally recommended by dermatologists may contain urea, hyaluronic acid, lipids, sunscreens, and anti-oxidants (such as Vitamin C).

Next week we'll review products and treatments for:

  1. Stimulating collagen production
  2. Reducing redness
  3. Reducing dark spots
  4. Reducing wrinkles

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583891/
https://www.aad.org/public/skin-hair-nails/younger-skin/selecting-anti-aging-products
http://www.mayoclinic.org/diseases-conditions/wrinkles/in-depth/wrinkle-creams/art-20047463

If you have any questions about skin care, please log into your account and send us your question. We are here to help.

Dr. Val Jones MD - Health Tip Content Editor

Health Tip: How To Manage Arthritis Pain

I was with some friends the other day who were bemoaning the fact that they were generally in good health, but their joint aches and pains were significantly impacting their daily lives. They asked me what I recommended for osteoarthritis. I winced a little bit because I knew that there is no perfect cure, and that most arthritis pain treatments have unwanted side effects when used long-term.

"Garden-variety" arthritis from wear-and-tear is called osteoarthritis. It is one of the most common causes of pain as we age. There are other kinds of autoimmune arthritis, where the body's immune system attacks joint tissue (such as rheumatoid and psoriatic arthritis) and those have different treatment options that I won't review here.

But if you're like 27 million Americans with osteoarthritis, you probably have tried several treatments already, without full relief of your pain. In summary, here are the options before you:
Mechanical Options

1. Exercise: Some find that their arthritis is worse in the mornings after having been still and asleep at night. People with osteoarthritis often say that "it takes a while to get going in the morning, but once my joints warm up I feel better." That's true for exercise as well (it reduces arthritis pain). Weight training can strengthen the muscles around arthritic joints, taking some of the strain off them. Simple walking can be helpful in reducing pain. Gentle stretching can improve joint flexibility and reduce pain.
2. Physical therapy: Therapists can provide a monitored program that reduces pain and provides assistive devices (such as canes, splints, orthotics, or walkers) to offload weight on a painful joint while still allowing maximum movement. Therapists may also use heat and massage to help with the pain.
3. Weight Management: Every additional pound of weight puts more pressure on joints that have worn out cartilage or bone spurs. It makes sense that losing weight reduces joint pain.
4. Surgery: In severe cases of arthritis, the joints are worn down to the point of grinding bone on bone. Once you reach a certain level of joint destruction, joint replacement surgery becomes a good option.

Medical Options

5. Acetaminophen (Tylenol) is still considered first-line therapy for arthritis pain. It does not reduce swelling at the site of the joint, but modifies pain perception in the brain.
6. Non-steroidal Anti-Inflammatory Drugs: include over-the-counter drugs such as ibuprofen and naproxen. They work by reducing inflammation at the site of the arthritis. The downside is that long term use of NSAIDs can cause stomach ulcers or bleeding in the intestinal tract. It is important not to take these medicines for too long, and to always follow the Drug Facts label recommendations for dosing.
7. Steroid Injections: may provide temporary relief of arthritis pain by flooding the area with a strong anti-inflammatory medicine. These cannot be used too frequently because they weaken bones and can make you prone to fractures.
8. Hyaluronic Acid Injections: the "shock absorbing" protein found in joint fluid may be injected into the joint as a temporary pain reducing measure. Most people depend on these injections as a bridge to surgery. One of the risks of these injections is joint infections.
9. Narcotic Analgesics: prescription pain medicines may be effective at reducing severe arthritis pain, but the risk for dependence and possible addiction is very high. Most doctors are now being urged (because of the opioid epidemic) to avoid prescribing narcotics for more than 7 days. Atypical narcotics such as Tramadol, are sometimes a reasonable short term option.

And that's pretty much it. I try to encourage my patients to be realistic about their pain management options - knowing that it's unlikely that the pain can be taken away completely. Arthritis management requires a multi-pronged strategy that mixes mechanical and medical options to keep pain from limiting activities and the enjoyment of life. In the end, "tolerable pain' rather than "no pain" may be as good as it gets.

References
http://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925
https://medlineplus.gov/osteoarthritis.html

If you have any questions about arthritis, please log into your account and send us your question. We are here to help.

Dr. Val Jones MD - Health Tip Content Editor