Sleep: What is Our Role as Physical Therapists?

Sleep.

It’s one of the few things every single one of our patient’s have in common. Young. Old. Male. Female. Thin. Overweight. Athlete. Couch-potato. Motivated. Uninvested. Orthopedic injury. Neurological condition. 

Sleep is guaranteed to be a part of each and every patient’s daily routine. Yet how many of us actually spend time discussing sleep with our patient’s? How many of us take the time to explain the profound impact sleep, or disordered sleep for that matter, can have on healing and pain perception?

To take it a step further, how many of the PTs out there feel like they had adequate education regarding sleep throughout their PT school curriculum to even be qualified to have these conversations with patients?

Personally, I know that I would frequently, and confidently, advise patients to get as much sleep as possible. Why wouldn’t I? That’s about the safest advice you can give any patient. But just telling someone to “get better sleep” would be like telling a post-op ACL to “just do better squats,” or telling a marathoner with patellar chondromalacia to “just run better.” It’s insufficient, ineffective, and irresponsible. 

When asked what they could do to improve their sleep, or when pressed on why exactly they needed to make sure they were getting quality sleep, I never felt I had answers satisfactory.

So let’s answer 2 simple questions.

1. Why is sleep so important to both pain and recovery?
2. What is a physical therapist’s role in a patient’s sleep?

Sleep & Pain

So why should you be asking each and every patient about their sleep?

Simple. Sleep is intimately related to cardiovascular function, fitness level, strength of immune system, memory, tissue recovery, pain, and mortality. Even when you control for BMI, gender, age, history of smoking, exercise, and medical history, diminished sleep is associated with increased mortality risk, increased morbidity, depression, and decreased energy.¹

So what qualifies as sleep deprived? 4 hours of sleep per night? 5? Actually, chronically getting anything less than 7 hours of sleep per night, and you’ll start to invite a slew of unwanted medical issues.¹ While we should be concerned about each and every one of these health detriments, let’s focus on those most pertinent to us as physical therapists. 

Sleep and Low Back Pain

Low back pain is the condition most commonly treated in outpatient physical therapy clinics^2,3, and despite an absolute abundance of research, there remains vigorous debate on the most effective form of treatment. One thing we can all agree on though is that we must use all tools at our disposal to address this epidemic. 

Patients with chronic low back pain take longer to fall asleep, are less satisfied with their sleep, experience more disturbances, and are less likely to enter restorative deep sleep.⁴ In fact, 46% of patients with chronic low back pain have a sleep disorder⁴ and those with chronic low back pain are 18x more likely to experience insomnia (difficulty initiating and maintaining sleep) specifically.⁵ While it is true that those with low back pain are more likely to experience insomnia, this relationship is bidirectional. People with insomnia will experience pain with greater intensity and frequency.⁶ 

Clinical Implications

Yet, it’s not just low back pain that is associated with disturbed sleep. Indeed, it is all types of pain. Compared to those subjects who obtained a full 8 hours of sleep, those subjects who were sleep deprived experienced a 42% increase in sensitization of the pain-related centers of the brain.¹ Even a single night without sleep causes drastic increases in cortisol levels and generalized hyperalgesia; and by simply limiting sleep, we see a decrease in endogenous nociceptive-inhibitory factors and a low-grade inflammatory response throughout the body, marked by an increase in inflammatory cytokines.⁵ In other words, your body’s threshold for painful stimuli sees a marked decrease. 

And what about sleep as it pertains to the day-to-day in the clinic? Well, a decrease in sleep results in impaired ability to learn new motor tasks¹…and we’re in the business of teaching people new motor tasks. In a study done on rats in which their brain/neural activity was monitored while learning a maze, it was found that when sleeping, the same pattern of brain-cell firing was noted…but this time at ½ or ¼ speeds.¹ Your brain continues to practice these motor patterns even after your body stops. So if you’ve ever had a patient who just can’t seem to learn a specific motor pattern no matter how many times you practice or what cues you give them…it may help to discuss their sleep with them. 

At an even more basic level, patients who get less sleep demonstrate decreased exercise intensity, decreased time to exhaustion, and decreased power output the following day.¹ Not only can that affect performance IN the clinic, but this is a critically important point to discuss with your athletes as it pertains to their sport performance. Getting less than 8 hours of sleep drastically lessens time to exhaustion and increases risk of injury. Specifically, getting 6 hours of sleep instead of 8 results in a 10-30% drop in time to exhaustion and an increase in risk of injury from 35% in those of obtained 8 hours of sleep, to a whopping 75%.⁷

Physical Therapist’s Role in Sleep

There are a lot of things we as physical therapists do for our patients. We improve performance, optimize movement, ensure safety with functional mobility, and generally improve quality of life. However, in most settings our primary goal is pain reduction. People with pain – musculoskeletal, nerve, joint, etc- come to us for our expertise in helping them resolve this pain. 

Since the argument could be made that our chief responsibility is pain reduction, we should be concerned with all things related to pain; from effective manual therapy techniques to pain neuroscience, and from proper body mechanics to sleep. All of these things are important pieces of the pain puzzle.

With limited education on the subject, you may ask yourself: “Is advising patients on sleep really within my scope of practice”? Well, as is true for most things, the answer is not cut and dry. 

Therapists can use the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), the Sleep Fullfillment Questionnaire, and the Athlete Sleep Screening Questionnaire (ASQI) to help identify disordered sleep; but once you’ve identified the problem, are we qualified and equipped to handle it? 

What We SHOULDN’T Do

There are certainly aspects of sleep management that fall outside of the scope of practice for therapists. Namely when it comes to medications. Some startling statistics exist regarding the impact that both pain medication and sleeping pills can have on the human body. 

Acute use of opioids can result in decreased REM sleep, decreased deep sleep, and decreased total sleep time.⁸ Of equal concern with the recent increase in use of medical marijuana for pain management, is that these same changes are seen with use of cannabis.⁸ 

If that weren’t enough reason for concern, how many of your patients take sleeping pills? Patients taking >132 sleeping pills a year (1 every 3rd day or so) have a 5.3x increase in all-cause mortality, and even those taking <18 pills a year see a 3.6x increase in all-cause mortality.⁹

Despite these concerns, it is not our place to advise that patient’s stop taking or alter the dosage of prescribed medication. If you’re concerned about the impact a patient’s pain medciation or sleep aid is having on their health, you should contact the referring physician or refer the patient to a sleep specialist. Although we shouldn’t tell our patients to quit taking their meds, improving sleep can decrease drug dependency.¹ So let’s talk about what we CAN do for our patients.

What we SHOULD do

One of the most effective forms of treatment for disordered sleep is Cognitive Behavioral Therapy (CBT), and most therapists use CBT for musculoskeletal problems without even knowing it. On a daily basis you’re getting your patients to question their beliefs about their body, getting them to believe in what they can do, and demonstrating how changing their thoughts/outlook/behaviors can actually change the way they feel. That’s CBT. A systematic review found high-quality evidence to suggest that a physical therapist-led CBT approach was effective at improving sleep and decreasing low back pain.⁵ 

So now apply that same approach to sleep. When patients say that their lower back is painful, you don’t respond by telling them “it is what it is and maybe it will get better with time,” you give them strategies to cope in the short term and work together to improve it in the long-term. The same should be true of sleep. To brush off a patient’s struggles with sleep, or to avoid discussing it all together, is a disservice to your patients (and quite frankly, to yourself as well). Use the following guidelines¹ from Dr. Matthew Walker’s book – Why We Sleep – to help your patients create achievable goals regarding sleep:

Sleep Checklist

1. Stick to a consistent schedule. Go to bed and wake up at the same time every day as often as possible. This is the most important piece of advice. 
2. Exercise regularly. While they should be doing this anyway with their HEP, educate them to not exercise in the 3-4 hour window before bed, as this can increase core body temperature and make it difficult to initiate sleep.
3. Avoid Caffeine. 
4. Avoid alcohol before bed, as this suppresses REM sleep. 
5. Avoid large meals, large drinks, and spicy food before bed. A light snack is okay, because going to bed hungry can be detrimental as well.
6. Naps are great! However, don’t nap after 3pm, as this can make it difficult to stick to your sleep schedule. 
7. Perform relaxing activities before bed such as reading or listening to music.
8. Take a hot bath/shower. This will cause peripheral vasodilation and well help to decrease core body temperature faster when you get out. Subjects who took a hot bath before bed demonstrated a 10-15% increase in deep sleep.
9. Keep the bedroom cool. Ideal temperature is around 65°.
10. Minimize screen time. Blue light can delay the release of melatonin. Keep the lights dim in the house and begin turning off the TV, tablet, and phone a few hours before your scheduled bed time. 
11. Don’t lay in bed. If you can’t sleep, get up and resume one of the relaxing activities we discussed before. 

As a side note, if you’re reading this and thinking “well, I work in neurorehab, this only applies to musculoskeletal pain”, think again! Stroke is the leading cause of long-term disability in the United States and in the 3-4 months after a stroke roughly 60% of patients will experience insomnia.¹⁰ Enhancing sleep can result in drastic increases in motor learning and performance of fine motor tasks through “off-line” memory consolidation.¹⁰ Ensuring proper sleep in the neurologically involved patient population is absolutely essential!

The Well Rested Therapist

Alright, I’ve gone on so long that most of YOU are probably asleep (which I would fully be in support of by the way). However, I didn’t want to end the article without talking about YOUR sleep. 

Life for a therapist, and most health care providers for that matter, across all settings is typically a life of long days treating patients, writing notes at home, continuing education courses, mandatory corporate compliance training, independent research on behalf of the needs of your patients, and so on and so forth. That’s not even taking into consideration your home and social life. To quote Ferris Bueller, “life moves pretty fast.” However, I would amend the end of that quote to “if you don’t stop and get the recommended 8 hours of sleep a night, your health, wellness, and occupational performance may suffer.” So, my version may not have quite the same ring to it, but it is true nonetheless.

Surgeons who get less than 6 hours of sleep the night before a surgery are 170% more likely to commit a serious surgical error in the OR.¹ And for the medical residents working 30 hours shifts out there, you are 460% more likely to make a diagnostic error towards the end of that shift.¹ We all owe it to ourselves and our patients to be well rested. So revisit that sleep checklist above. Time to follow our own advice.

If you’re interested to learn more about this subject, get Dr. Matthew Walker’s book, Why We Sleep. I can’t recommend it highly enough. 

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References

1. Walker, M. (2017). Why We Sleep: Unlocking the Power of Sleep and Dreams. Penguin Random House. 
2. Maher  C, Underwood  M, Buchbinder  R.  Non-specific low back pain.  Lancet. 2017;389(10070):736-747. doi:10.1016/S0140-6736(16)30970-9
3. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976). 1995;20(1):11-19.
4. Kelly, Gráinne A. MSc, BSc*; Blake, Catherine PhD, MSc, BSc*; Power, Camillus K. MD†; O’Keeffe, Declan MD‡; Fullen, Brona M. PhD, BSc* The Association Between Chronic Low Back Pain and Sleep: A Systematic Review, The Clinical Journal of Pain: February 2011 – Volume 27 – Issue 2 – p 169-181 doi: 10.1097/AJP.0b013e3181f3bdd5
5. Jo Nijs, Olivier Mairesse, Daniel Neu, Laurence Leysen, Lieven Danneels, Barbara Cagnie, Mira Meeus, Maarten Moens, Kelly Ickmans, Dorien Goubert, Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice, Physical Therapy, Volume 98, Issue 5, May 2018, Pages 325–335, https://doi.org/10.1093/ptj/pzy020
6. Haack M, Scott-Sutherland J, Santangelo G, Simpson NS, Sethna N, Mullington JM. Pain sensitivity and modulation in primary insomnia. Eur J Pain. 2012 Apr;16(4):522-33. doi: 10.1016/j.ejpain.2011.07.007. PMID: 22396081; PMCID: PMC3627385.
7. Milewski MD, Skaggs DL, Bishop GA, Pace JL, Ibrahim DA, Wren TA, Barzdukas A. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 2014 Mar;34(2):129-33. doi: 10.1097/BPO.0000000000000151. PMID: 25028798.
8. Angarita, G.A., Emadi, N., Hodges, S. et al. Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: a comprehensive review. Addict Sci Clin Pract 11, 9 (2016). https://doi.org/10.1186/s13722-016-0056-7
9. Kripke DF, Langer RD, Kline LEHypnotics’ association with mortality or cancer: a matched cohort studyBMJ Open 2012;2:e000850. doi: 10.1136/bmjopen-2012-000850
10. Catherine F Siengsukon, Lara A Boyd, Does Sleep Promote Motor Learning? Implications for Physical Rehabilitation, Physical Therapy, Volume 89, Issue 4, 1 April 2009, Pages 370–383,