Physical Therapists’ Role in Addressing Acute Insomnia: Could We Prevent Chronic Insomnia—and Chronic Pain?
Year: 2021
Type: article
Abstract: Over 60% of adults in the United States report experiencing a sleep disturbance several nights per week, and 30% to 40% report symptoms of insomnia.1 Insufficient sleep and poor sleep health can impair function of the immune system; increase pain perception and lower pain threshold; decrease cognitive function, learning, and memory consolidation; reduce overall quality of life; and increase risk of accidents and falls.2–4 Furthermore, poor sleep health is associated with an increased risk of chronic health conditions, including, diabetes, obesity, cardiovascular disease, and depression, and increased mortality.2,6,7 Similarly, circadian rhythm dysfunction (dysfunction in the 24-hour sleep/wake cycle) can lead to disruption in healing from injury, metabolic regulation, memory consolidation, hormone release, eating habits, and other body functions and can contribute to the development of various chronic health conditions.7 There is little information on the prevalence of sleep disturbances or insomnia in patients receiving physical therapy services. Over 90% of individuals with chronic low back pain receiving physical therapy services report poor sleep quality.8,9 In a sample of 88 patients receiving physical therapy services,10 we found that 51% scored a 10 or greater on the Insomnia Severity Index, indicating increased risk of insomnia,11 and 78% scored >5 on the Pittsburgh Sleep Quality Index, indicating poor sleep quality.12 This high prevalence of insomnia symptoms and poor sleep quality in individuals seeking physical therapist services highlights the need for physical therapists to screen for sleep disturbances and provide sleep health promotion techniques. In 2020, the American Physical Therapy Association House of Delegates adopted a position on the role of the physical therapist in sleep health, which solidifies our “part of an interdisciplinary team of licensed health services providers in prevention and management of sleep impairments and promotion of healthy sleep behaviors.”13 The high prevalence of insomnia symptoms and poor sleep quality in individuals seeking physical therapist services also begs the questions: (1) Could physical therapists help prevent an acute bout of insomnia from transitioning to chronic insomnia? (2) Could mitigating insomnia help prevent acute pain from transitioning to chronic pain or be a treatment avenue for people with chronic pain? To consider these questions, we must first consider how insomnia develops. A well-accepted model to explain the development and perpetuation of insomnia is Spielman’s 3P model of insomnia (Fig. 1).14 This model proposes that predisposing factors are physiological (ie, genetic predisposition for insomnia, hyperexcitable nervous system), psychological (ie, anxiety, tendency to ruminate), social (ie, bed partner or child[ren] that impacts sleep), and environmental (ie, noisy or unsafe neighborhood) and increase the risk of developing insomnia. Typically by themselves (at our resting state), predisposing factors do not cross the threshold to trigger insomnia. The precipitating factors are the event(s) that, when combined with predisposing factors, cross the threshold and trigger an acute bout of insomnia. For individuals seeking physical therapist services, the precipitating event could be an injury, a surgery, a stroke, or the onset of a condition such as multiple sclerosis (to name a few). For most individuals seeking physical therapist services, there is an “event” that necessitates these services. Hence, many of the patients we treat are likely at risk for developing insomnia or are already experiencing an acute bout of insomnia. 3P model of insomnia. Adapted with permission from Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10:541–553. Sleep health promotion strategies to be tailored to the individual. The outline of the sleep hygiene circle is a dashed line to indicate sleep hygiene is typically not recommended as a stand-alone intervention. Also note that the amount and type of education provided will vary depending on the individual’s unique sleep health disturbance. Adapted from Siengsukon C. Sleep Health. In: Tatta J, Garner G, eds. Lifestyle Medicine in Physical Therapy. Orthopedic Physical Therapy Products; anticipated 2022. The final “P” in the 3P model of insomnia is perpetuating factors. These are the behaviors that people with subacute insomnia often develop to manage their sleeplessness (ie, spending more time in bed with the hopes they will “catch up” on sleep, napping, doing activities in bed other than sleeping, staying in bed while awake) as well as the negative thoughts that develop surrounding insomnia (ie, “I’m going to be so tired tomorrow,” “I’ll never sleep again”). As time passes, the precipitating event is mitigated (ie, the patient recovers from their injury/condition) or reduced (ie, the patient learns to manage their chronic condition). However, if the perpetuating factors continue, they can keep the person over the insomnia threshold and chronic insomnia ensues. The focus of cognitive behavior therapy (CBT) for insomnia to treat chronic insomnia is on the perpetuating factors. Because physical therapists often treat people following a precipitating event, we are in a prime position to prevent perpetuating factors from occurring or to mitigate their impact to prevent the transition of acute insomnia to chronic insomnia. I propose 4 strategies to do this: (1) normalize that sleep may be disrupted following injury/surgery/etc and that it should be short-term while the body heals/recovers; (2) encourage an increase in sleep duration initially if needed (such as a longer sleep opportunity window, early bedtime/later rise time, and naps) because sleep has been shown to promote healing and recovery15,16 but return to their typical pre-injury sleep duration and regular sleep schedule as soon as able; (3) tailor sleep health promotion education (entrain circadian rhythm; increase sleep drive; reduce pre-sleep arousal; general sleep hygiene17; Nijs et al18 and Siengsukon et al,17 provide sleep management techniques for physical therapists; Fig. 2) as appropriate for the individual’s unique sleep health disturbance and considering there may be an initial need for increase in sleep duration; and (4) refer to a behavioral sleep medicine provider if insomnia symptoms continue following recovery from or mitigation of their injury or condition that led them to seek physical therapist services. We developed a decision tree to aid physical therapists in screening patients for sleep disturbances,20 and a next step is to validate the sleep decision tree in a clinical setting. Although there are numerous short- and long-term health consequences of sleep disturbances,2,3 the impact of sleep disturbances on pain modulation is directly applicable to physical therapist practice. Sleep insufficiency results in increased pain sensitivity, a lower pain threshold, and the development or exacerbation of pain symptoms through multiple systems.21 Even 1 night of sleep loss results in increased pain sensitivity and impaired pain modulation in healthy, young adults.22 A recent critical review reports that longitudinal studies and experimental studies “support the notion that sleep impairments are a stronger, more reliable predictor of pain than pain is of sleep impairments.”23 Sleep has been identified as a target of interest for pain relief as well as potentially preventing progression of acute pain to chronic pain.21 Indeed, CBT for incomnia24,25 used alone or combined with CBT for pain26 in individuals with chronic pain conditions has resulted in improvements in sleep outcomes as well as pain outcomes. With sleep disturbances contributing to impairments in pain modulation and increasing risk of development of chronic pain conditions,23 it seems plausible that physical therapists addressing sleep issues within our scope of practice and/or referring to the appropriate health care professional when needed may help prevent acute pain conditions from transitioning to chronic pain. Evidence already supports that treating insomnia improves sleep and pain outcomes,24–26 and sleep restoration mitigates the effects of sleep deprivation on pain sensitivity and vulnerability.27 A next step for the field of physical therapy is to determine if integration of sleep health promotion techniques into physical therapist treatment of individuals with pain conditions impacts sleep, pain, and recovery. CS is owner and CEO of Sleep Health Education, LLC. The author completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no other conflicts of interest.
Source: Physical Therapy
DOI: 10.1093/ptj/pzab285
Author: Catherine Siengsukon
Institution: University of Kansas Medical Center
Language: English
Topic: Sleep and related disorders
Subfield: Experimental and Cognitive Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: bronze
OpenAlex ID: W4200029435