Do you treat pain? Do you measure this critical contributor to pain?

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One of the clinical benefits of living in an attractive, remote location is that you get to meet a range of travellers from around Australia and the world. It is my n=1 litmus test for other clinicians' treatments for common clinical presentations. The most common presentation we all treat is pain, and from my experience, one element of pain that isn't being treated relates to sleep. Let's explore...

Common Presentation

A traveller presented yesterday who I will call Leslie. In her mid-30s, she was very fit and had just completed a 'Tough Mudder' equivalent on the East Coast, for which she had been training for 6 months. For the past 10 years, she regularly saw a clinician for headaches, tight shoulders and occasional low back pain. She put these pains down to various things: having children, a T-bone car accident 5 years prior, heavy training and the build-up for occasional competitions. Let's return to Leslie's situation after reviewing what the researchers are exploring.

Pain & Sleep

Background: If you are interested, you can read an extensive critical review on the association between pain and sleep here.

The article I want to focus on is titled "Day-to-day associations between pain intensity and sleep outcomes in an adult chronic musculoskeletal pain population: A systematic review."

This article reviews research examining the day-to-day variations of chronic musculoskeletal presentations. What we used to call acute or chronic is now more commonly called flares of a chronic problem. These are the clinical presentations where simple time and healing have not resolved the symptoms, and this is where the detective work or fun starts for a clinician.

The authors reported, "A bidirectional relationship between pain intensity and sleep was found. Nine articles indicated that night-time sleep quality was a more consistent predictor of next-day pain intensity than vice versa."

Leslie was experiencing what I call circadian spine symptoms. These symptoms peak in the early morning and generally improve with the day, and then rinse and repeat fairly regularly. Note that it doesn't have to happen every night/morning because other factors are at play. Also, because the symptoms usually improve over a few hours, the client does not recognise their significance unless specifically asked. Further, they may report feeling 'fragile' or a bit susceptible to pain on sudden movements or awkward postures during the day. Again, it is temporary, but we are starting to join the clinical dots. In Leslie's case, the focus was her spine, which can also be her hips and shoulders. Other peripheral joints are less often but possible.

I asked detailed questions about her sleep system (i.e. pillow, bed, mattress and coverings), sleeping arrangements (i.e. partner, kids, pets, room) and sleep posture. A client-specific educational session follows about the importance of sleep, how and why she wasn't benefiting from her sleep and why her symptoms were ongoing regardless of how much exercise she did or how many treatments she had paid for. This education session is critical because we are about to change behaviour, and there are certain psychological stages for our client to move through for this to be successful. Below is a slide from Dr Jeremy Lewis's The Shoulder illustrating these stages.

On presentation to our clinic, clients like Leslie have already reached Stage 2.

As noted above, we then complete Stage 3, our assessment and a tailored education session. I love it when clients say, "Why has nobody explained this to me before?" If they say this, you know you have adequately addressed Stage 3. The client is primed, onboard, and ready for Stage 4!

Stage 4 is then delivered. I also take this opportunity to explain what is likely to happen in the future - a relapse. I do this to alert them to the importance of what they are doing right now and that nothing is permanent. If they revert to their previous behaviour, their symptoms will logically return. Cause and effect.

Leslie's case relates to spinal pain, but because every human system goes south if we are not achieving adequate sleep, it doesn't matter whether your clinical forte is elite athletes, GLA:D participants, unhealthy weight individuals, suffers of rheumatological conditions or mental health conditions, they will all benefit from a comprehensive sleep assessment and targeted sleep improvement programs. As primary contact practitioners, we can assist our clients much more deeply when we include their sleep quality and quantity in our evaluation.

Some clinician-specific resources available to assist you on your sleep education journey include;