by Andrew Davidson
In this series, we'll look at current common approaches to managing pain and illness in our healthcare system. With the example of sleep deprivation, we’ll show how some factors still misunderstood and often ignored can lead to worsening health and poorer outcomes in some patients. We’ll also look into ways to improve rehabilitation of such patients by stepping away from some of our current healthcare beliefs.
Edit: All statements are backed up so please leave a comment if you want more info / references. Any questions or debate are of course welcome.
The impact of sleep on pain: still misunderstood and often ignored
In the 21st century most people have a love/hate relationship with sleep. In the 1800's sleep was a highly romanticised topic, evident in literature and music (Shakespeare's Caesar for instance, oh sweet release). After the industrial revolution, these views changed drastically with sleep being viewed as a burden, a simple function that can easily be ignored and neglected (Margaret Thatchers's 'sleep is for wimps'). For years little has been known about why we actually need sleep at all, and several theories have been proposed. It is only recently that we have come to understand just how important sleep is to overall well being, and its ties and associations to worsening health and higher mortality rates are increasingly evident.
The average day can roughly be divided into 3: 8 hours sleep, 8 hours work and 8 hours private life - although it could likely be argued that sleep and private life are under-prioritised, especially in increasingly difficult economies and worsening housing markets. Sleep therefore accounts for up to 30% of your life, that means you will spend anywhere from 25-30 years asleep.
Why do we need sleep? Some theories...
Sleeping means not moving which in theory does lead to energy conservation, but the overall 'savings' are relatively small, estimated at approximately 110 calories. For such a highly complex experience this hardly seems a particular good use of 25-30 years of your life.
Sorting through and filtering experiences and memories collected during the day?
Freud introduced this in his famous book Dream Psychology over 100 years ago but this is more difficult to prove scientifically, at least until we fully understand the complexity of dreams. There does appear to be an element of information interpretation, but not everyone experiences or remembers dreams; and night terrors, sleep paralysis and nightmares are highly common experiences which can disrupt sleep significantly. It is therefore more helpful to consider this process a secondary bi product of sleep, but not the underlying reason.
The third theory is a more recent understanding based on highly complex investigations initially done on mice, and this is where the science becomes interesting:
The body has a natural cleaning mechanism which is called the lymphatic system. Cells and organs filter their waste products into the blood stream via the lymphatic system in order for it to be broken down and filtered away. But if we look at the brain we see that it isn't connected to the lymphatic system. Instead, while we sleep, the brain's cerebrospinal fluid 'washes' over our brain cells who shrink and expel proteins, predominantly a large protein called amyeloid beta. So lack of sleep disrupts the brains ability to essentially 'clean' itself.
Whilst not a cause and effect relationship, Alzheimer's patients have been shown to have an abundance of amyeloid beta build up on the brain, and it is associated with long term deteriorating cognition, including memory loss and difficulties in processing information. These are common symptoms reported by chronic pain patients.
What's the relevance to overall health?
The effects of sleep deprivation on physical health is increasingly understood, and new research findings are alarming. Sleep deprivation releases glucose into the blood stream, in the long run this can make someone insulin resistant and cause Type 2 diabetes. Furthermore it releases hormones into the system which affects metabolism: in simple terms it makes you crave carbohydrates. The risk of developing obesity is 50% higher among those sleep deprived, aggravated by associated tiredness, lack of motivation and therefore deconditioning from lack of exercise.
Stress and anxiety are common in the sleep deprived, releasing cortisone into the system, raising heart rate and blood pressure as well as releasing bursts of adrenalin through a fight-or-flight response. Hypertension and high cholesterol are therefore common, increasing risk of cardiovascular disease.
As this state continues to spiral, long term chances of cancer are also raised; often in the lung/bowel/prostate as rates of smoking and drinking are higher in this population, particularly in people from poorer socio-economic demographics.
It is worth mentioning drug and alcohol misuse as it is associated with various health issues, including sleep deprivation. Alcohol can put someone to sleep or ease the transition into sleep, but only through sedating the person, which prevents the brain from 'cleaning' itself (as discussed above). The risk of long term abuse and addiction is significant with an added risk of further co-morbidities.
We need a true shift in the health care paradigm
As health care professionals working with chronic pain patients we have to think holistically: pain is a multidimensional experience influenced by all aspects of someone's life. Tissue damage is the least interesting finding in someone struggling to manage persistent pain, and new models advocate a 'top down' approach (i.e the embodied cognition model), by modulating and improving psychological health then grading the person's exposure to exercise or movement.
We need to stop just talking about the biopsychosocial model and fully appreciate that there is no separating physical and mental health. A human being as a collection of parts requires all systems to be working to enjoy quality of life, and the mind is one of those parts.
The key outcome initially is to provide understanding - this ties in nicely with Peter O'Sullivan's classification based model for lower back pain (a philosophy I personally believe is applicable to all pain presentations). By learning what can harm or negatively impact your mental health, we can improve the chances of being able to predict the outcome of that impact. Sticking with the sleep deprivation example, understanding what constitutes good sleep hygiene may lead someone to stop certain behaviours that lead to poor sleep, such as watching TV or drinking coffee/alcohol right before bed, because they can now predict that the outcome will be tiredness, affected memory, low mood, even disrupted sex life (and much more).
However, simply understanding something doesn't improve motivation or energy levels, especially if someone is already sleep deprived, stressed, anxious or depressed. If that was the case no health care professional or doctor would ever get sick. But if a GP or health care professional was not only aware of but also actively screening for issues related to psychological and emotional well-being, patients could be made aware of the effects, be educated and given resources to learn more and be signposted to appropriate treatments. This could include NHS referrals but also apps, books, web sites, podcasts, even support groups, lunch clubs for the elderly, sleep clinics and alcohol/drug assist services. This may then increase the chances of someone making the effort to implement changes.
Failing model of healthcare?
Now imagine if your patient starts developing back pain (or other joint pains), maybe with some leg pain often randomly called sciatica. The patient may wait for a while hoping symptoms will resolve, but eventually often ends up in A&E where they'll receive pain killers and will be advised to go home and book an appointment with their GP. When the patient eventually sees the GP, they may well be told that they have arthritis or/and a disc bulge in their back. Alternatively an (often completely unnecessary) MRI will be ordered, which research shows correlates very poorly with symptoms.
These two arbitrary terms, "disc bulge" and "arthritis", can be very distressing to a patient, but are, to a therapist working in chronic pain, uninteresting findings which do very little to inform the treatment plan.
Over the first decade, prescriptions for opioids, MRI scans, spinal injections and surgery levels for back pain have risen by 20-30%. At the same time, disability levels for lower back pain have increased by 15-20%, with a chronicity prevalence of 80% and life time prevalence reaching 60-70%. Even more alarmingly, back pain prevalence among adolescents and children have also risen, being 3-4 times higher in Western Europe compared to the rest of the world. 133 million work days are lost annually in the UK with lower back pain listed as the most prevalent cause. That is a not only a huge loss of productivity and cost, but a damning presentation of what could be called a failing model of health care.
The data has actually been available since 2001. A study was done on two groups of patients receiving their imaging results (n=3000). One group received their written report as usual, and the other added a brief introduction of normal results found in the pain free population at the end of the report. Needless to say the latter group demonstrated significantly better measures of self efficacy, pain as well as clinical outcomes. Their study was simple as it was elegant; 65% of the pain free population have disc bulges and 43% have annular tears in their discs without any symptoms or functional limitations.
A new diagnosis has therefore emerged: "Victims Of Modern Imaging Technology", or "VOMIT". Just like a nocebo effect, patients being told their back shows "damage" or "crumbling", is "worn out", "looks like that of a 70 year old" or is "stiff", "immobile", "out of alignment", often end up with further fear of movement, increasing tension and stiffness, persisting pain, sleeplessness, health anxiety, low mood which again affects their ability to work or stay in employment - affecting financial health further increasing anxiety in a never ending evil circle.
Only after people have been through packets of medication with ever increasing strength - from Paracetamol and Ibuprofen, to Co-codamol and Naproxen, to Diclofenac, Amitriptyline, Pregabalin, Gabapentin, perhaps an antidepressant like Citalopram, then a gastro protector like Omeprazole, eventually ending in repeated injections of corticosteroids, a trial of Tramadol (the equivalent of medical heroin), not excluding Methadone which is actual medical heroin and is also in rare cases prescribed - only does the patient end up in a pain clinic, where they more often than not are told their pain cannot be taken away and they need to learn how to live with it. Can you imagine the impact that this can have on someone's self efficacy and rehab potential?
Only then they might be introduced to mindfulness, pacing, the actual importance of diet and exercise, sleep hygiene, talking therapy, movement retraining, education and advice about what is actually happening in their nerves, muscles and brain. And whilst it is never too late to improve someone's symptoms, it is certainly much more difficult once all aspects of the patient's life have been affected, and significant health care beliefs have been formed. These beliefs form barriers that can take a long time to brake down before rehab can be begun. If someone is convinced their back is crumbling or that movement is harmful, it is a huge challenge to introduce new ways of thinking - especially considering the effects sleep deprivation has on memory and the ability to process and analyse new information. The term 'backfire effect' is used here to explain why when someone is introduced with new evidence informed information, instead of accepting it and changing their beliefs and behaviours, these beliefs are often strengthened even further.
This phenomena is in no way limited to patients, in fact it would seem the prevalence is greater among health care professionals through prevailing paradigms. Why haven't we started including normal findings in MRI scans? The knowledge is publicly available and evidence shows it can improve outcomes, there were no findings to show it did any harm. Are there financial reasons? Possibly, but in the NHS we certainly cannot afford to spend money on unnecessary and potentially harmful investigations. We may never find out exactly why. But raising awareness (or understanding and predicting) may be the first step in introducing change.
And if that fails, you can always use data; presenting findings to a local commissioner and show how money can be saved and outcomes improved. Money really does talk.
It all ties together
I believe understanding and predicting can lead to control, again based on the O'Sullivan approach. If you can understand your symptoms you may be able to control your symptoms, you can have greater control of your life. Being a human being does not mean feeling well at all times, everyone experiences highs and lows in the mental and physical wellbeing, we are dynamic animals and this is how our bodies work. But all too often symptoms go unrecognised or untreated, treatment is stigmatised and people get stuck in a failed healing response. Unfortunately health care professionals (some more than others, I will come to this in a different article) can often create and reinforce unhelpful beliefs which can affect on someone's quality of life.
We have touched on the concept of sleep deprivation and how it ties in with worsening health and poorer outcomes.There is no absolute pathway, guideline or cure for any one of these symptoms but understanding how they interlink is important. Based on the data, it would seem our approaches to managing pain and illness are still single dimensional. I will try and address more specific ways of doing so in the next 3 entries, the next one will be related to (gently) debunking a few health care beliefs, followed by a guide to rehabilitation.
About the author
Andrew is a Senior Physiotherapist based in East London. He primarily specialises in the management of chronic musculoskeletal pain but also works in research, particularly the management of tendinopathies. He has presented his work to a number of conferences around the UK and as a result has built up an extensive network of contacts he has made available to QualifiedPhysio. Andrew also runs our MSK seminar and has contributed to the writing of our MSK interview pack.