Making Sleep Part of Your Practice: Practical Strategies to Incorporate Now

[00:00:00] So if you're a clinician out there looking for a simple tool, you don't know much about

[00:00:04] CBTI or what to do with your folks who aren't sleeping well, download the app, check it

[00:00:08] out yourself and you can easily work with your patient or client through that process

[00:00:14] to help make some positive change.

[00:00:16] If anybody's out there saying, well, I don't think that's within our scope.

[00:00:19] It absolutely is.

[00:00:20] And the APTA, you know, gives us some really good guidelines on that.

[00:00:25] It goes to again, fit the treatment to the person in front of you, not to like this

[00:00:29] is my menu of stuff that I'm just going to impose upon you as a patient.

[00:00:35] Can be a source of anxiety.

[00:00:37] And if it is a source of anxiety, the wearable may not be the right fit for you.

[00:00:41] What is going on everybody and welcome back to another episode of The Modern Pain Podcast.

[00:00:45] This week we did something a little different.

[00:00:46] I wanted to take the podcast on the road.

[00:00:49] So I recorded at the Pain Science in Motion Conference at Las Vegas this past weekend.

[00:00:53] You're going to need to cut me some slack.

[00:00:55] I did record and I didn't realize till after I spent an hour talking to Brett that the

[00:01:01] recording of me was a bit blurry.

[00:01:02] So it bothers me.

[00:01:03] My OCD is struggling with it, but please cut me some slack.

[00:01:07] And again, this week we talked to Brett Nielsen.

[00:01:08] He's a colleague and friend.

[00:01:10] He's been doing some publishing.

[00:01:11] He did a scoping review on the incorporation of sleep measures in research around chronic

[00:01:15] low back pain.

[00:01:16] He had some surprising results in his research as it really showed that we really

[00:01:19] don't take sleep into account when we're researching chronic pain conditions.

[00:01:23] We talked about that.

[00:01:24] We talked about wearables and we basically talked about ways clinicians can use certain

[00:01:28] applications that are out there for free that you can use with your patients that

[00:01:31] are pretty easy to use.

[00:01:33] So this episode is full of good value.

[00:01:34] I think you're going to enjoy it.

[00:01:36] Again, cut me some slack.

[00:01:37] Enjoy the episode.

[00:01:39] This is The Modern Pain Podcast with Mark Cardula.

[00:01:44] All right, Brett Nielsen, welcome to the first live Modern Pain Podcast episode.

[00:01:49] It's good to have you joining us, man.

[00:01:50] Yeah, it's good and good to be here.

[00:01:52] We go back a little bit.

[00:01:53] We did fellowship together.

[00:01:55] You were a little bit after I went through, but can you kind of introduce yourself?

[00:01:59] My name is Brett Nielsen and I'm a physical therapist.

[00:02:02] Let's see.

[00:02:03] Since 2009 graduated from University of Puget Sound and through my gosh, I guess

[00:02:09] it's 15 year career now, I've done all sorts of different things from clinical

[00:02:15] practice to running a clinic to running a couple large randomized controlled trials

[00:02:22] through some government grants in San Antonio area.

[00:02:27] And most recently, I am a full time professor for the Hawaii Pacific

[00:02:34] University and DPT program, which started in 2022.

[00:02:38] Yeah, that's that's a rough gig having to go out to Honolulu a few times a year.

[00:02:41] And your home base is where again?

[00:02:42] Yeah, home base is in Seattle, Washington.

[00:02:44] So yes, as you noted, I commute to Honolulu when I need to be on campus,

[00:02:51] as it's a hybrid program.

[00:02:52] So it's pretty fun.

[00:02:54] Yeah.

[00:02:54] And you're one of your content areas that you've talked about is sleep.

[00:02:57] That's a big part and probably a topic that we're getting a little bit more

[00:03:01] commonly to discuss in PT.

[00:03:03] Can you talk a little bit about the research you've been up to in sleep

[00:03:06] and kind of what you're doing at the moment with that?

[00:03:09] Yeah, absolutely.

[00:03:10] So let's see.

[00:03:11] Gosh, December 2021, I wrapped up a doctor of science program.

[00:03:18] So this is like secondary, more academic focused doctorate degree from Bellin

[00:03:23] College, and that was a great experience.

[00:03:26] But through that, I really got interested in sleep with one of my

[00:03:31] colleagues who was going through the program, Dr.

[00:03:34] Mark Shepard, who you also know very well.

[00:03:36] And then one of our mentors was Dan Roan.

[00:03:40] Chris Dickerson was also part of our team there, one of the another

[00:03:43] fellow student.

[00:03:44] And yeah, we just got really interested in in sleep.

[00:03:47] And it actually started when we started thinking about trials for chronic pain.

[00:03:53] And there's so much evidence now out there that links sleep and pain together.

[00:03:59] Right. So it's very common if you're dealing with chronic pain, you're

[00:04:02] probably not sleeping well and perhaps vice versa as well.

[00:04:07] If you're not sleeping well, you're more likely to be dealing with

[00:04:09] chronic pain.

[00:04:11] And so we started getting interested interested in, well, you know, all of

[00:04:15] these randomized controlled trials for chronic back pain, as an example.

[00:04:20] Are they even looking at sleep?

[00:04:21] Right. Are we missing a huge component to somebody's overall health and wellness?

[00:04:26] And in fact, we started digging into the research and realized, wow, there's

[00:04:30] five published guidelines for researchers who are conducting

[00:04:35] randomized controlled trials.

[00:04:36] And all five of these, you know, to varying degrees, recommend the

[00:04:40] collection of a sleep disturbance measure specifically.

[00:04:46] And so we got curious about, like, well, how many of these trials are actually

[00:04:49] following this?

[00:04:51] Because we read a lot and we don't always see sleep showing up in the

[00:04:56] literature. And so that was kind of one of the big projects that got us

[00:05:00] started is doing a scoping review.

[00:05:04] Yeah, I'm curious what what you found in the review as far as when it

[00:05:07] looks at, because it's always interesting when you hear these like guidelines

[00:05:11] of how we should be conducting research and especially when it's the

[00:05:14] authority kind of areas of like the folks that are really the leaders of

[00:05:18] discussing sleep.

[00:05:19] And then you do some some digging to see, well, hey, are these publishers

[00:05:23] or these authors utilizing what's been recommended?

[00:05:26] And what did you all find with that?

[00:05:28] What we found is that the large majority.

[00:05:33] So we specifically looked at chronic low back pain trials.

[00:05:36] We needed to kind of zone in on an area that's highly researched to get a

[00:05:41] sample of like, is this happening?

[00:05:43] So essentially we were looking at all published trials for chronic low back

[00:05:48] pain. And we narrowed in between 2010 through the end of 2022, which is

[00:05:53] when we wrapped up our analysis.

[00:05:56] And out of that, we identified two hundred and eighty two trials for

[00:06:00] chronic low back pain. And these are not just conservative, you know,

[00:06:03] physical therapy trials. These are pharmacological surgery and various

[00:06:08] conservative aspects from physical therapy to yoga, to mindfulness,

[00:06:12] et cetera. And out of those two hundred eighty two trials, less than

[00:06:16] 10 percent actually capture any measure of sleep.

[00:06:21] And that may even just be like once at baseline or asking a specific

[00:06:24] sleep question. So it's less than 10 percent.

[00:06:28] There was 26 total trials out of 282.

[00:06:32] And then we essentially developed a tool to kind of evaluate the

[00:06:39] level of incorporation. Right.

[00:06:41] So like a score of one indicated that they collected sleep at baseline

[00:06:46] but didn't touch it again. Right.

[00:06:48] It doesn't show up any other time in the publication all the way to a

[00:06:52] measure of four, which is a specific validated sleep disturbance measure

[00:06:57] that was captured at multiple time points.

[00:07:00] So baseline and maybe the end of the study or several others.

[00:07:05] And that would have kind of been the optimal adherence essentially.

[00:07:07] And so out of that, only 13 actually met the true like

[00:07:12] adherence to the guidelines, which is less than five percent.

[00:07:16] So there's a big opportunity here.

[00:07:19] And it's not to call out any researchers. Right.

[00:07:21] I mean, I think there's that's I want to be really careful there as

[00:07:24] I'm a researcher myself.

[00:07:26] And there's so much information out there that it's it's tough.

[00:07:29] Also, the amount of, you know, things that you have to collect.

[00:07:34] Right. There's this survey fatigue.

[00:07:36] So you kind of have to, you know, what's most important to our aim.

[00:07:39] But there is a huge opportunity that if more trials were following

[00:07:44] the guidelines, that we could better understand the link between sleep

[00:07:47] and pain. And maybe it's, you know, we're trying to treat the pain,

[00:07:51] but maybe we should be addressing the sleep and or and the pain will,

[00:07:54] you know, improve just as an example. So.

[00:07:56] Yeah. And I don't think anybody who's listening is going to be surprised

[00:07:59] that when you don't sleep well, I mean, I think we can all probably

[00:08:02] relate to the fact that when you're under slept and you have kids,

[00:08:05] I have a kid and we've been through we've been through the

[00:08:08] the times where sleep has been a hot commodity as far as not getting much of it.

[00:08:13] And I definitely can relate to just body in general, not feeling good

[00:08:17] and things. And it's interesting when we have all this published data,

[00:08:21] how little that's been kind of piqued at.

[00:08:23] You've had the opportunity this week and we're at the Pain Science

[00:08:27] in Motion Conference here in Las Vegas.

[00:08:29] Adrian Low's group and the Pain in Motion Group from Belgium

[00:08:32] are putting on a great conference.

[00:08:33] I don't know where it's going to be.

[00:08:34] It's going to be here or somewhere in two years.

[00:08:36] So keep your eyes on online with that.

[00:08:38] And we'll link Brett's study that he's speaking to online as well.

[00:08:42] But they talked about sleep in your in your pre-con.

[00:08:45] You did a full day of discussing sleep.

[00:08:47] I'm wondering any major pearls of wisdom that you got from that stuff

[00:08:52] that somebody who's listening to a clinician can kind of grab onto

[00:08:55] of some ways we can maybe intervene, examine, intervene with

[00:08:58] what somebody who's dealing with some sleep challenges.

[00:09:01] Yeah, yeah. So I attended a full day kind of sleep workshop,

[00:09:05] if you will, or pre-con yesterday with Niels and Celine from Belgium.

[00:09:10] And it was fantastic session.

[00:09:14] I think, you know, just I guess maybe some big nuggets is that,

[00:09:18] you know, all of us can be involved in sleep.

[00:09:20] And if, you know, those out there listening aren't aware,

[00:09:23] the American Physical Therapy Association has a specific position on sleep.

[00:09:28] If you just go to APTA.org, you type in, you know, sleep.

[00:09:33] It's one of the first things that's going to pop up there.

[00:09:35] And it very clearly identifies the role of the physical therapist.

[00:09:38] So if anybody's out there saying, well, I don't think that's within our scope.

[00:09:41] It absolutely is.

[00:09:42] And the APTA, you know, gives us some really good guidelines on that.

[00:09:48] So that's, you know, number one.

[00:09:50] And, you know, what was really presented was,

[00:09:53] you know, kind of a comprehensive approach. Right.

[00:09:55] So what are, you know, some of the screening questions? Right.

[00:09:59] So are we, you know, it can be as simple as just asking your

[00:10:02] your patients or your client that you're working with, you know,

[00:10:05] how are you sleeping?

[00:10:06] How long are you sleeping?

[00:10:07] And do you typically feel well rested in the morning?

[00:10:11] Those can be some really great conversations to or some questions

[00:10:16] to start the conversation around sleep and help you as a practitioner decide,

[00:10:20] you know, is this something that I need to take note of that we maybe need

[00:10:23] to screen a little bit more in depth or is there potentially an underlying

[00:10:27] problem here that again, we need to refer on?

[00:10:30] Or is this something that we can address, you know, here in the clinic

[00:10:34] through some very simple,

[00:10:36] you know, sleep health education, some behavior modification, et cetera.

[00:10:42] There's a I took a course recently.

[00:10:45] I was up at the Michigan P.T.

[00:10:46] Association thing and there was a did they talk about any apps?

[00:10:50] There's one, the CBTI, which I think is through the VA system,

[00:10:53] if I remember correctly.

[00:10:55] I'm not saying they use that from Belgium, of course,

[00:10:57] but any tools out there that clinicians and we'll link the CBTI

[00:11:01] to folks who are listening or watching this.

[00:11:04] Any tools or things that they've recommended or maybe ones

[00:11:07] you've come across, too, in your in your studies and publishing

[00:11:10] a lot of great stuff on it?

[00:11:11] Yeah. So Neils and Celine, you know,

[00:11:15] apps are a little bit different in Belgium, but we did

[00:11:18] bring that up yesterday and discuss it.

[00:11:20] So in fact, CBTI was like the really the central focus

[00:11:24] of yesterday's pre con.

[00:11:26] And if you're not familiar with what that is, it's cognitive

[00:11:29] behavioral therapy for insomnia.

[00:11:31] And insomnia is one of the top three sleep diagnoses

[00:11:35] that your patients may be dealing with with sleep apnea

[00:11:38] and restless leg syndrome being the other two common ones.

[00:11:41] But insomnia, by far, is the largest,

[00:11:43] and it's the one that we can absolutely make an impact on.

[00:11:47] But yeah, so as far as like easy clinical tools,

[00:11:50] CBTI Coach is fantastic, comes from the VA.

[00:11:54] It's 100 percent free.

[00:11:56] And it's recently went through an update to

[00:12:00] so it actually now can link up to any of your wearable technology

[00:12:04] has a sleep diary in there.

[00:12:06] It has your primary measures.

[00:12:09] So obviously, you know, there's the

[00:12:13] PSQI, which is the Pittsburgh Sleep Quality Index.

[00:12:17] You've got the ISI, which is another one, right?

[00:12:20] Insomnia severity index is probably the best measure for

[00:12:23] screening more in depth for somebody who's dealing with insomnia.

[00:12:28] And then one that's really interesting that we've actually used

[00:12:30] in a different research study is called the DBAS,

[00:12:33] which is the dysfunctional beliefs and attitudes about sleep.

[00:12:37] It's a 16 question screener

[00:12:40] that really looks at maybe some of them,

[00:12:43] you know, misperceptions around sleep

[00:12:47] and some of the maybe the maladaptive beliefs around sleep.

[00:12:51] Like a common one is I need eight hours, right?

[00:12:53] If I'm not getting eight hours, I'm not getting enough sleep.

[00:12:56] But, you know, we know that everybody needs a different amount of sleep.

[00:12:59] Right. So but, you know, the kind of the society

[00:13:02] and the media really pushes this eight hour, you know, perfect window.

[00:13:07] So that's embedded within the app as well.

[00:13:08] So if you're a clinician out there looking for a simple tool,

[00:13:11] you don't know much about CBTI or what to do with your folks

[00:13:15] who aren't sleeping well, download the app, check it out yourself.

[00:13:18] And you can easily work with your patient or client

[00:13:21] through that process to help make some positive change.

[00:13:25] So, yeah, having just peeked at the app a bit,

[00:13:28] haven't used it a ton with clients yet.

[00:13:30] It is definitely it's it's well put together.

[00:13:32] It has, like you said, those integrations with wearables.

[00:13:35] We talked a lot about wearables today in our pain, sense and motion course.

[00:13:39] We had Matthew Smook, who's a physician at the Stanford

[00:13:44] medical system, did amazing talk on that.

[00:13:47] I'm wondering if they talked about this and maybe if they didn't.

[00:13:50] What your thoughts are on it, because I sometimes and I think

[00:13:53] I get this way to where I almost get anxious about my sleep.

[00:13:56] And I sometimes the more I get thinking about my sleep

[00:14:00] and I have to do this about my sleep or I got it

[00:14:02] where it almost becomes like sleep anxiety about me not sleeping.

[00:14:05] And the more I kind of engage with some of that stuff.

[00:14:08] Did they talk about that or if not, again, was there anything

[00:14:11] that you've come across as far as that issue?

[00:14:14] Yeah, and that's that's probably one of the biggest challenges

[00:14:17] with bringing more attention to sleep.

[00:14:20] I mean, it's a multibillion dollar industry.

[00:14:22] You just turn on the TV and you are getting ads for different apps

[00:14:27] or different beds or all of these different things to help you sleep better.

[00:14:32] And and then also the societal pressures of like, what's the ideal?

[00:14:36] And unfortunately, everybody is different.

[00:14:38] We all have kind of our own sleep signature, if you will,

[00:14:42] kind of like a pain signature that, you know, is unique

[00:14:46] to every single individual.

[00:14:47] So you can't compare yourself against somebody else.

[00:14:50] It's about finding what is the right thing for you

[00:14:54] and what's working for you.

[00:14:57] Not to interrupt you, but with that,

[00:15:00] how does somebody come up with what's right for them?

[00:15:04] Is it strictly like a subjective, like, hey, I've been keeping track.

[00:15:08] This is how much I get and I feel this way as I kind of maybe journal.

[00:15:11] I take diaries and I kind of assess, like, especially if you run wearables,

[00:15:15] you might have metrics and things like that that they're going off of.

[00:15:18] Is there anything that helps somebody calculate?

[00:15:21] Because, of course, I mean, we can all go on Instagram

[00:15:23] and there's everybody in their brother who's got the answer of this

[00:15:25] is the exact amount of sleep that everybody should have.

[00:15:28] Any way that you found or heard in your studies and research

[00:15:31] that kind of helps somebody kind of narrow in on or maybe a physio

[00:15:35] or somebody clinician trying to help somebody narrow in on

[00:15:37] what's the amount of sleep that's best for them?

[00:15:39] Yeah, this is a big key takeaway.

[00:15:41] And I'll try to fuse your previous question there, too, about wearables.

[00:15:46] Yeah, one of the big challenges that can be a source of anxiety.

[00:15:51] And if it is a source of anxiety, the wearable may not be

[00:15:54] the right fit for you.

[00:15:56] It's really not intended to give you data day to day.

[00:16:01] Right. I like to think of it as like zoom out, collect a lot of data passively,

[00:16:06] but maybe check on it once a week to kind of say, you know, how am I doing

[00:16:09] and compare that against your own internal, you know,

[00:16:14] thoughts, you know, feelings of like, you know, am I getting enough rest?

[00:16:18] So that's kind of my approach to the wearables.

[00:16:20] All the wearables, too, aren't super accurate.

[00:16:23] And they depending on what you're wearing, etc.,

[00:16:26] there can be quite a bit of variability.

[00:16:28] So that's where you could have a really great night of sleep

[00:16:31] and you pull up your app and you go, oh, man, I slept crummy.

[00:16:35] And then that changes your perception on your sleep

[00:16:38] when, in fact, you probably did sleep pretty well.

[00:16:39] And it was your wearable that wasn't positioned quite right

[00:16:41] or move too much, etc.

[00:16:44] But yeah, so getting back on track, like what is right for you as an individual?

[00:16:49] And this was something big nugget or takeaway from that pre con is

[00:16:54] quality of sleep is so much more important than quantity of sleep.

[00:16:58] So we can almost throw the number out the window

[00:17:01] and it has a lot more to do with the quality and just asking yourself,

[00:17:04] are you feeling well rested in the morning when you wake up?

[00:17:08] And we're not talking about like the minute you open your eyes.

[00:17:11] But like in that first half hour, do you feel like I'm ready to go?

[00:17:14] I'm ready to start my day.

[00:17:16] You probably got a pretty good quality of sleep.

[00:17:18] Now, if you're dragging and you're like, oh, my gosh,

[00:17:20] I just having a hard time doing everything.

[00:17:22] I'm snapping at my my kids or my family.

[00:17:25] I really don't want to get in this work thing.

[00:17:27] I'm about to type this nasty email, right?

[00:17:29] You probably didn't get a great night of sleep.

[00:17:31] And so kind of getting really good at just understanding

[00:17:35] where you're at can give you a lot of insight into your quality.

[00:17:40] But if I can take that one step further, the big takeaway from

[00:17:43] this pre con yesterday is that you really want your sleep

[00:17:47] efficiency in that like 80 to 85 percent zone.

[00:17:51] And what that means is it's the total time in bed

[00:17:55] compared to the total time asleep.

[00:17:57] So your time asleep should be about 80 to 85 percent

[00:18:02] of your total time in bed, right?

[00:18:05] It's natural to be in bed and it to take 15 to even a 30 minutes

[00:18:10] to fall asleep.

[00:18:12] And that would be part of your kind of awake time in bed.

[00:18:14] And that's normal.

[00:18:15] So 80 to 85 percent.

[00:18:17] If you're getting,

[00:18:19] you know, if you're well up in like the 95 percent,

[00:18:21] that probably means you need to increase the amount of time

[00:18:24] that you spend in bed.

[00:18:26] So you're giving yourself more of a sleep opportunity. Right.

[00:18:29] Now, if you're on the other side and your your efficiency is way low,

[00:18:33] you're probably actually spending too much time in bed

[00:18:36] and you want to restrict or shorten

[00:18:39] the amount of time you're spending in bed to achieve more of that 80 85 percent.

[00:18:44] So just kind of some general ballpark.

[00:18:45] And again, that shouldn't be a source of anxiety.

[00:18:48] But if like you're in that kind of 80 ish window,

[00:18:51] you're probably doing pretty well.

[00:18:53] So I like the thoughts of a big picture,

[00:18:56] 10,000 foot view, maybe looking at it after a week of collection.

[00:19:00] I, you know, says the guy wearing an Apple

[00:19:02] watch and a woop strap at the same time where I got Apple and or us.

[00:19:06] So you're you're equally guilty.

[00:19:09] And, you know, I do it for fitness and other means, not just sleep, too.

[00:19:13] But I can definitely see how it becomes a source of anxieties for some folks.

[00:19:18] And you get hyper analytical to the point.

[00:19:21] And I think it's important for us as clinicians, right,

[00:19:23] to recognize that patient, I think we and I see this in myself

[00:19:26] sometimes anxiety over things I have to just like, you know, put the phone away,

[00:19:29] put your woop app down or put your Apple health app away

[00:19:33] for a little bit and just chill about it and not get so wrapped up in it.

[00:19:37] Because my wife will roll her eyes at me then, Mark.

[00:19:39] You know, you're getting a little bit too hung up on this thing.

[00:19:42] And of course, you know, I want to live long and be there for the kids

[00:19:45] and all that stuff. I know you're in the same boat.

[00:19:49] One of the things that commonly gets used

[00:19:53] and toss around out there like mindfulness or like almost meditation type stuff.

[00:19:57] Where's your position and maybe where do you think in clinical practice?

[00:20:01] And again, maybe what you've came up with in your pre con

[00:20:04] when it comes to utilizing those type of things as like part of your

[00:20:08] sleep kind of treatment of yourself or as kind of sleep management program

[00:20:12] for yourself.

[00:20:13] Yeah, those can be great relaxation strategies.

[00:20:17] But I think that's the key is the relaxation strategy.

[00:20:20] So finding what works best for you to wind down in the evening

[00:20:25] when you're preparing for sleep.

[00:20:27] So that could be, you know, relaxation or mindfulness or breathing activities.

[00:20:32] It could be simply reading a book.

[00:20:33] There's a fantastic research study that was done many years ago

[00:20:36] at the University of Sussex that shows that reading for about six

[00:20:40] ish minutes is great at like winding down, like decreasing anxiety

[00:20:46] and lowering heart rate, et cetera.

[00:20:50] But also, you know, sometimes TV gets a bad rap. Right.

[00:20:54] And like you can't watch TV or, you know, limit the blue light before,

[00:20:59] you know, half hour or an hour before bed, et cetera, et cetera.

[00:21:05] But the research actually, and we talked about this yesterday

[00:21:08] in the pre con is that the research actually is maybe showing

[00:21:11] that blue light is maybe not as important as we thought it was,

[00:21:15] or maybe not as impactful as we thought it was.

[00:21:18] So if watching TV helps you wind down in the evening,

[00:21:22] by all means, that's great.

[00:21:23] So probably matters more of the content of what you're watching

[00:21:26] or even reading, right?

[00:21:27] If like you're into this book that you can't put down,

[00:21:30] that's probably not your best go to for bedtime.

[00:21:33] So, yeah, it really doesn't matter as far as like if you're not

[00:21:36] into mindfulness or meditation, that's OK.

[00:21:39] But that can be a great opportunity for helping wind down

[00:21:42] and reflecting on the day and yourself,

[00:21:46] just putting yourself in that present moment. Right.

[00:21:49] Yeah, it's interesting, you know, and it's again,

[00:21:50] it's a patient by patient thing.

[00:21:52] And you got to fit the person in front of you.

[00:21:53] I just, you know, we get someone it tends to be the

[00:21:56] highly testosterone driven male where I'm doing that meditation stuff.

[00:22:00] There's a bunch of hokey stuff and not everybody,

[00:22:02] you know, there's some folks that are very receptive to it

[00:22:04] in different things. But it goes to, again, fit the

[00:22:06] treatment to the person in front of you, not to like,

[00:22:09] this is my menu of stuff that I'm just going to impose upon you

[00:22:11] as a as a patient.

[00:22:15] Where do you think the barrier is?

[00:22:17] Because maybe not barriers to work, but, you know,

[00:22:20] it's not been something I don't know about you,

[00:22:21] but was sleep hygiene or sleep even discussed in PT school?

[00:22:24] I mean, maybe a few passing mentions.

[00:22:26] But for me and my PT training, I didn't get pretty much

[00:22:29] minimal about sleep. You?

[00:22:32] Yeah, no, that was not a topic.

[00:22:35] I'm not even sure, you know, even came up at once, right?

[00:22:38] And I'm not sure I was sleeping super well through PT school.

[00:22:42] Yeah, exactly. I mean, just I mean, it's always interesting.

[00:22:45] Like I work in a clinic that's in a university.

[00:22:48] So I see a lot of students and it's a fascinating study of like

[00:22:52] when you are at your highest stressed, underslept eating like crap,

[00:22:56] you know, the life of a grad student where, you know,

[00:22:58] we see all these pain issues and stuff go on.

[00:23:00] So I guess it's interesting to see this stuff materialize

[00:23:03] in the populations that we serve as as, you know, academic faculty as well.

[00:23:09] With that said, with with the lack of it being introduced,

[00:23:13] I know you teach you're in academia and do things.

[00:23:16] I think you do some lifestyle medicine

[00:23:18] and corporations into your into your teachings.

[00:23:21] Where do you think we need to go to help students kind of get

[00:23:25] at least have a basic knowledge?

[00:23:27] Because like you said, there's an app you can get to where

[00:23:29] you're going to have pretty dang good resources

[00:23:32] at the in the palm of your hand for a patient.

[00:23:33] And again, you that you can study and go.

[00:23:36] But is in your curriculum over there at HPU,

[00:23:39] is that something that you're incorporating some of that

[00:23:41] as far as sleep, at least educating students

[00:23:44] so they're prepared to have that discussion

[00:23:46] and that question that we spoke about with sleep?

[00:23:48] Yeah, it it is.

[00:23:51] Of course, I always love more.

[00:23:53] But yeah, it is it is part of the curriculum.

[00:23:55] And in fact, we bookend the curriculum.

[00:23:59] So right in first term, they're getting health promotion

[00:24:02] and fitness management course, which does dive into nutrition

[00:24:07] and sleep and, you know, de-stressing and,

[00:24:12] you know, avoidance of smoking and things of that nature.

[00:24:16] Right. So we kind of get into some of those like health

[00:24:18] components right from the beginning.

[00:24:20] Again, it's more of an exposure

[00:24:22] and it's meant to, you know, get the get

[00:24:26] the student thinking about the whole person,

[00:24:28] but also reflecting on their own behaviors and self.

[00:24:32] We've had students in the past, right, who've really struggled

[00:24:35] because they weren't sleeping at all.

[00:24:37] Right. They're just trying to do it all

[00:24:39] and not prioritizing the right things.

[00:24:41] And we still need even though you're busy,

[00:24:43] you still need the basic necessities of sleep

[00:24:46] and proper nutrition and movement.

[00:24:48] So we try to bolster that at the beginning.

[00:24:50] And then we teach a two credit pain science course

[00:24:53] at the very end of the curriculum, which that gets,

[00:24:56] you know, fused into as well.

[00:24:58] Now with the more of the lens of like how sleep is impacting

[00:25:01] pain or playing a role in persistent pain.

[00:25:04] And what better time to learn some good sleep habits

[00:25:07] than when you're in graduate school,

[00:25:08] where it is a tough go to get sleep.

[00:25:10] I just remember, you know, waking up at four in the morning,

[00:25:13] you know, three, three thirty in the morning,

[00:25:15] stressing about studying and not sleeping and having those moments

[00:25:19] where I was just running on fumes and, you know,

[00:25:20] we see it in our students regularly.

[00:25:22] And so, yeah, I mean, that great case study of yourself

[00:25:26] as a clinician, as a student or as somebody who's

[00:25:28] who's dealing with some sleep stuff to start working with this stuff.

[00:25:31] Because I think the more we can kind of embody it

[00:25:34] in our own behaviors, the more easy it is to start

[00:25:37] educating your patients and your clients on maybe

[00:25:40] incorporating some of that stuff.

[00:25:43] Where do you where do you see sleep?

[00:25:46] Any things that you got going on your plate

[00:25:48] that in as far as research or I know you're doing a poster

[00:25:51] this weekend that is going to speak to I don't know if it's

[00:25:54] speaking to your scoping review or if it's other things.

[00:25:57] But where do you see research or what's what's coming down

[00:26:00] the pipeline as far as maybe some ways that we're going to

[00:26:02] improve maybe P.T. and not just P.T.

[00:26:06] because it's obviously P.T.s don't own sleep nor should we.

[00:26:10] But it's definitely something that, as you've pointed out

[00:26:12] nicely, that APTA has given us and people need it.

[00:26:16] Right. And we definitely are capable of having those discussions.

[00:26:19] But where do you think, you know, I guess,

[00:26:21] what things are coming on the pipeline for you?

[00:26:23] Anything that you got going on research wise and then if not,

[00:26:26] where do you think sleep training needs to go as far

[00:26:30] as to get it to be a little bit more of a common thing

[00:26:33] that we're doing as a physical therapist or as a clinician

[00:26:35] who's dealing with people in pain?

[00:26:37] Who had such a loaded question.

[00:26:41] I think this this the simple answer is if more clinicians

[00:26:46] were interested in their patient or client sleeping

[00:26:50] habits like that already would be a big win,

[00:26:53] because if you're able to at least screen for sleep

[00:26:56] impairments and refer those individuals to a provider

[00:27:00] that can help them, even if you don't feel comfortable

[00:27:03] dealing with it like right there, that can be a huge,

[00:27:07] you know, success, right, or a huge opportunity

[00:27:10] for the person that you're working with.

[00:27:13] But then I think it is very feasible for everyone

[00:27:16] to be informed about, you know, some helpful behaviors

[00:27:21] that can help influence a better night of sleep

[00:27:24] and working with their patient, understand what they're doing

[00:27:27] and working with the client or patient to understand

[00:27:30] like what kind of changes they might be interested in trying.

[00:27:33] Right. Because it's not a one size fit all.

[00:27:35] And if you just start throwing your education out there about sleep,

[00:27:39] you're more likely to cause anxiety and frustration

[00:27:42] than actually getting, you know, moving the needle.

[00:27:45] So maybe choose one thing.

[00:27:46] Maybe it's just choosing a wake up time, right?

[00:27:49] That's one of the most important things is getting up

[00:27:52] at the same time every single day within a half hour. Right.

[00:27:55] So maybe on the weekend, you give yourself

[00:27:56] a little more flexibility with about a half hour,

[00:27:59] maybe our maximum,

[00:28:01] because then the time to go to bed and getting a better night

[00:28:05] sleep will actually kind of come with that. Right.

[00:28:07] Because if you have a crummy night's sleep

[00:28:08] but you're getting up the same time,

[00:28:10] your sleep drive is going to be that much greater

[00:28:12] the night after and you're going to, you know,

[00:28:14] go to sleep very quickly and get a really nice,

[00:28:16] solid night of sleep.

[00:28:18] So I think that's, you know, kind of future.

[00:28:20] What I hope for the profession is that we just get more

[00:28:23] comfortable with understanding sleep and talking about it.

[00:28:27] As far as, yeah.

[00:28:28] So this tomorrow I'll be presenting on the scoping review

[00:28:32] that I've covered and talked about.

[00:28:34] And then I have a poster on a secondary research study

[00:28:37] that I did with the same group, Mark Shepherd

[00:28:40] and Chris Dickerson and a few of our professors

[00:28:43] instructors at Bellin College, Jody Young and Dan Rohn

[00:28:47] and Eric Chaconis.

[00:28:48] But we actually, the other thing in physical therapy,

[00:28:52] there's not great data on like how many people

[00:28:54] walking into our clinics are actually not sleeping well.

[00:28:56] So we essentially, we employed, not employed,

[00:29:00] but we created an opportunity for fellowship students

[00:29:05] needing scholarly work and had them collect data for us

[00:29:10] at about 10 different states around the country.

[00:29:12] And we collected data on any patient coming into PT

[00:29:16] for a new evaluation for spine pain.

[00:29:17] So it could be thoracic, lumbar, cervical.

[00:29:21] And we essentially had them fill out a battery

[00:29:23] of things and one of them was the DBAS,

[00:29:26] that dysfunctional beliefs about sleep questionnaire.

[00:29:29] And then looked at like how many people are showing up

[00:29:32] into the clinic with who aren't sleeping well.

[00:29:35] And lo and behold, as you can probably imagine,

[00:29:39] about half and then two thirds of them

[00:29:42] are not getting great quality of sleep either.

[00:29:45] And then they also have dysfunctional beliefs

[00:29:48] about their sleep, which is strongly correlated.

[00:29:50] So if you don't have great beliefs about sleep,

[00:29:52] you're not sleeping well.

[00:29:54] The correlation coefficient for that was 0.7,

[00:29:57] which is really, really high.

[00:29:59] And the R squared is 50, 0.5,

[00:30:03] which really means that 50% of the factors

[00:30:08] that go into not sleeping well

[00:30:09] has to do with what you think about sleep.

[00:30:12] So that was like one of the big kind of take homes

[00:30:15] from that study and that really kind of sets us up

[00:30:20] for future work on like, all right,

[00:30:22] so now we better understand maybe

[00:30:24] what some of these thoughts and beliefs are.

[00:30:26] Oh, and also how that's influencing pain.

[00:30:29] So then we looked at basically for every point higher

[00:30:33] on the DBAS, which is a 10 point scale,

[00:30:36] your pain score is going up by a half point, right?

[00:30:40] So they're strongly related.

[00:30:42] So that just kind of sets us up for future research.

[00:30:44] We're in the process of looking for some grant funding

[00:30:47] to do some intervention trials up at Bellin College.

[00:30:53] One thing I've heard, and I've had these concerns too

[00:30:56] because I think sometimes in the clinic

[00:30:57] when somebody's like an acute pain, right?

[00:30:59] They have an acute angry sciatic issue

[00:31:02] where the clinician might say,

[00:31:04] well, let's just talk about your sleep.

[00:31:06] And in that context, it's like the patient,

[00:31:08] you're kind of missing the mark a little bit.

[00:31:10] And then that's probably an extreme example.

[00:31:12] So I think, because I'm assuming there's gonna be

[00:31:14] straw man arguments of like,

[00:31:16] well, you're just like telling everybody to sleep.

[00:31:17] You're not even telling them,

[00:31:18] you're not even worried about their pain.

[00:31:19] You think sleep is gonna cure it all,

[00:31:20] which I know you and I know all the researchers

[00:31:23] that you're involved with.

[00:31:24] That is absolutely not the case,

[00:31:25] but it's something that's an additive thing

[00:31:27] as you're still doing the good things

[00:31:29] that we do as physical therapists,

[00:31:31] chiropractors and others to help people manage pain.

[00:31:33] So I'm guessing that you would envision a program

[00:31:38] that might help people positionally from a mechanical,

[00:31:41] can we put them in positions that help their pain,

[00:31:42] but also helping some of the sleep hygiene practices

[00:31:45] as well.

[00:31:46] So it's not like we talk about the sleep

[00:31:48] and just do a diary without focusing on pain.

[00:31:51] Now again, some people when it's more

[00:31:53] of a chronic persistent thing

[00:31:54] where maybe using some mindfulness

[00:31:56] where we're diverting attention away from pain

[00:31:58] might be a helpful thing,

[00:31:59] but is that kind of the thought you have too,

[00:32:02] as far as like it's part of a big picture of management,

[00:32:05] not like sleep and then to the detriment of addressing pain.

[00:32:08] Cause I just wanna address any comments

[00:32:10] that might hit us in the comment section here

[00:32:12] that people are gonna tend to throw.

[00:32:13] Well, you're just talking about sleep and nothing else

[00:32:15] and what about the pain that they're dealing with?

[00:32:17] And well, if they're not sleeping,

[00:32:19] it's probably due to their pain,

[00:32:19] which is probably true to an extent

[00:32:22] for some patients for sure.

[00:32:23] But some of these mindfulness things

[00:32:25] and different things,

[00:32:26] especially if you incorporate some of the ACT stuff

[00:32:28] can help people have,

[00:32:30] be able to experience pain and downgrade,

[00:32:33] maybe be able to handle that uncomfortable sensation

[00:32:36] being present yet still be able to drift off to sleep.

[00:32:38] What are your thoughts on around that?

[00:32:39] Yeah, that's why I think we've gotta get comfortable

[00:32:42] with talking about sleep with our patients and clients

[00:32:46] because not to bring up another polarizing topic,

[00:32:49] but I will in posture, right?

[00:32:51] So as we all know as physios,

[00:32:52] like posture can be relevant and important, right?

[00:32:55] Especially with the person who like comes in

[00:32:57] with a neck pain, they say,

[00:32:58] oh, it hurts like this.

[00:32:59] And they're sitting in a super slouch position,

[00:33:01] you get them sitting up tall and they're like,

[00:33:03] yeah, that feels a bit better, right?

[00:33:04] Posture is relevant in that case.

[00:33:07] And so if you don't address the posture,

[00:33:09] you're probably not going to address the neck pain.

[00:33:14] But in a lot of other cases,

[00:33:15] posture probably has nothing to do with why they hurt,

[00:33:17] right?

[00:33:18] So I think this is the same thing here

[00:33:20] where sleep might play a role, but it also may not.

[00:33:24] They may have been a crummy sleeper

[00:33:26] well before their pain ever started.

[00:33:28] And so now is not the time to start trying

[00:33:31] to fix their sleep because it's probably not relevant

[00:33:34] to what's going on, right?

[00:33:35] Let's address the pain thing first,

[00:33:37] getting moving more back to the things they wanna do.

[00:33:40] And then lo and behold, oh, by the way,

[00:33:42] now would you like to talk more about sleep, right?

[00:33:44] That might be something that will help you

[00:33:46] enjoy life better,

[00:33:47] maybe prevent your pain from coming back, right?

[00:33:50] So I think that's where we got,

[00:33:51] we have to get comfortable talking about pain

[00:33:53] and asking those important questions

[00:33:56] to understand is this relevant

[00:33:58] and is this something that needs intervening now?

[00:34:01] But like you said, it's an adjunct.

[00:34:03] It's a component to the overall treatment package.

[00:34:05] And I think that's where I've seen the profession evolve

[00:34:10] in my 15 years of practice is when I got out,

[00:34:13] it was all about the knee hurts.

[00:34:15] So we're just gonna focus on this part of the region,

[00:34:18] right?

[00:34:19] And then we got into regional interdependence.

[00:34:20] And so we said, okay, we gotta look at the ankle

[00:34:22] and the hip too, and maybe the back, right?

[00:34:24] And then now we're like progressed to,

[00:34:26] we've got to look at this whole person

[00:34:28] because his knee is attached to a living, breathing,

[00:34:31] feeling emotional human being

[00:34:33] who may or may not be sleeping well, right?

[00:34:35] So then we gotta think about the whole person

[00:34:37] and what's going on with them

[00:34:39] and how this thing is affecting them

[00:34:42] and what's driving it.

[00:34:43] So you're absolutely right.

[00:34:45] Yeah, it goes on to like have a communication,

[00:34:48] establish a relationship with a patient

[00:34:50] where you're talking,

[00:34:51] you're not just like going into sleep training

[00:34:54] because this little screening tool said they're not sleeping.

[00:34:56] So you immediately dive into that,

[00:34:58] you have a conversation, you get to their narrative,

[00:35:00] you see, well, like you said,

[00:35:01] like if you talk to them

[00:35:02] and they haven't been sleeping for 20 years yet,

[00:35:04] this thing's just been going on for three,

[00:35:06] it may not be the lowest hanging fruit out there

[00:35:08] to start getting after.

[00:35:09] But I think sometimes we go on the course,

[00:35:11] we've all had that availability bias

[00:35:12] where man, I just went on a sleep course

[00:35:14] and I'm gonna go tackle everybody's sleep

[00:35:16] whether they need it or not.

[00:35:18] And that's where,

[00:35:19] everybody you go to your McKenzie course,

[00:35:20] your MNIP course, and everybody on Mondays get in

[00:35:22] because that's just where your head's at.

[00:35:25] No, I think that's a good way to go about it

[00:35:27] and just to kind of see the big picture of it.

[00:35:29] And I agree, it's refreshing.

[00:35:31] And I think our patients,

[00:35:33] we talk to patients on the podcast

[00:35:34] and I'm sure we all have patients in our practice

[00:35:37] who have conditions that are way more

[00:35:39] than just the knee, right?

[00:35:40] And then our friend, Jilletta Belton

[00:35:43] always reflects back or often will reflect back

[00:35:45] on how she was termed the two o'clock hip

[00:35:48] where we need to do better and we're doing better.

[00:35:49] And it's refreshing to see that,

[00:35:51] especially when patients have these complex issues

[00:35:53] that have been invaded much more than just their knee.

[00:35:56] It's invaded their life and their relationships

[00:35:58] and their work and their function in society

[00:36:01] and all the different things that we keep on and on with.

[00:36:05] Anything you think,

[00:36:06] you've brought some great points of course.

[00:36:08] Anything else you think we need to talk about as PTs

[00:36:11] or anything else, any other kind of movements

[00:36:14] you think we need to make on the sleep

[00:36:16] when it comes to kind of managing,

[00:36:17] best managing people in pain?

[00:36:19] I think the only other thing that comes to mind that I,

[00:36:22] again, I want it's like a slippery slope

[00:36:25] that you wanna be careful around is just because

[00:36:27] somebody has poor habits around sleep.

[00:36:29] If they're sleeping well and don't mess with it, right?

[00:36:32] Or if they're not interested in messing with it,

[00:36:34] they may have the worst behaviors

[00:36:36] but they're getting a great night's sleep

[00:36:37] and feeling well rested in the morning.

[00:36:39] Like don't mess with that, right?

[00:36:41] It's not a one size fits all.

[00:36:44] So again, it just comes back

[00:36:45] to getting to know your patient or client

[00:36:48] which we as PTs are set up so well to do.

[00:36:51] And that's why I think we do play a critical role

[00:36:54] in the realm of the whole person,

[00:36:58] and that includes sleep.

[00:37:01] Couldn't agree with you more, man.

[00:37:02] I just wanted to thank you for sitting down

[00:37:04] for the first live experience here.

[00:37:06] If there's any camera issues or any mic issues,

[00:37:08] we're gonna chalk it up to take one

[00:37:10] that we've done this with.

[00:37:11] But it's been good to get to hang out with you

[00:37:14] here in Las Vegas.

[00:37:15] We've been doing all study and no gambling,

[00:37:17] no anything, it's been all just good nerding out on pain.

[00:37:20] But thank you for joining me today

[00:37:21] and thank you for all the good work you're doing.

[00:37:23] Yeah, absolutely.

[00:37:24] Thanks for having me.

[00:37:24] For those of you watching,

[00:37:25] we'd love to have you subscribe on YouTube

[00:37:27] wherever you're listening to this podcast.

[00:37:28] We'd love to have you subscribe there.

[00:37:29] If you're dealing with difficulties,

[00:37:31] understand where sleep fits in your practice

[00:37:34] or know somebody who's having difficulties

[00:37:35] fitting that into their practice,

[00:37:37] share this episode with them

[00:37:38] so maybe they can kind of bump their practice forward.

[00:37:40] But we will all talk to you next week.

[00:37:43] This has been another episode

[00:37:44] of the Modern Pain Podcast with Dr. Mark Karjula.

[00:37:48] Join us next time as we continue our journey

[00:37:50] to help change the story around pain.

[00:37:52] For more information on the show,

[00:37:53] visit modernpaincare.com.

[00:37:55] This podcast is for educational

[00:37:57] and informational purposes only.

[00:37:59] It is not a substitute for medical advice or treatment.

[00:38:01] Please consult a licensed professional

[00:38:02] for your specific medical needs.

[00:38:04] Changing the story around pain.

[00:38:06] This is the Modern Pain Podcast.