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Sleep Should be Part of Every Treatment Plan

Zach Walston working on a triathlete's foot after a race.

Having crucial conversations

Previously I have discussed in detail the art of patient education. A key point covered was educating a patient is more than simple regurgitation of information, regardless of the packaging. Education is best when delivered in bite-size packets, repeatedly, and when the patient is willing and interested in learning. Regardless of the approach taken, some information is harder to deliver than others. While physical therapists do not have to deliver the same type of news as physicians regarding life-altering diagnoses, they still run across situations that lead to difficult conversations.

I would venture a guess that most, if not all, clinicians have been on either the receiving or giving end of at least one difficult or crucial conversation. These conversations are not exclusive to patient care. Employee to employee crucial conversations – such as holding a clinical standard – are commonplace (depending on the culture of a practice). Training in crucial conversations is often provided to those in or entering leadership positions. These encounters are not exclusive to the ‘low performer’ conversation and performance reviews. Opportunities for difficult conversations will frequently appear during patient care. While there are many potential reasons for them, I am going to focus on the arena of patient education, specifically conversations on lifestyle habits.

Over the next three posts, I will dive into ‘the why’ behind integrating sleep, nutrition, and physical activity education into a plan of care. You may have thought “duh” when reading physical activity, this topic is often brushed over. Physical activity needs are far more than walks around the neighborhood. That may be a starting point, but it is far from the needed threshold for health. Bringing up these topics can be uncomfortable and often lead to resistance. Why are they uncomfortable? To answer this, I will turn to Brené Brown and her books Daring Greatly and Dare to Lead.

Brown’s research is primarily focused on vulnerability and shame. These are typically the primary reason for a clinician being hesitant to have conversations on lifestyles; if they do occur, they are often poorly conducted. Brown defines vulnerability as uncertainty, risk, and emotional exposure. Experiencing vulnerability is not a choice, but we are able to decide how we respond to it (shout out to stoicism, can’t go wrong with Meditations or Man’s Search for Meaning to learn more).

You may be put off by the “touchy, feely” vibe you are receiving right now. Putting our heads in the sand won’t change patient and clinician vulnerability and the role it plays in healthcare delivery. As Brown put it, “Perceived vulnerability, meaning the ability to acknowledge our risks and exposure, greatly increases our chances of adhering to some kind of positive health regimen. The critical issue is not about our actual level of vulnerability but the level at which we acknowledge our vulnerabilities around certain illness or threat.” So how do we help patients acknowledge their risks and exposures?

 

Establish trust

Brace Yourself

To facilitate a successful crucial conversation, it is vital we establish trust with our patients. A primary way to build trust is to listen to our patients and be patient. Trust grows over time and it strengthens when we feel heard and valued. This in turn allows both parties to freely give and receive advice without fear of judgment. When judgment enters the equation, our perception of self-worth comes along for the ride. When a patient – or anyone for that matter – feels their self-worth is on the line, they are far less likely to open up. This is when we reach the proverbial fork in the road. As tempting as it may be to take the advice of the wise New York Yankees legend Yogi Berra and “take the fork”, we need to decide whether we will take a step back and focus on continuing to build trust or push forward and force the conversation. The danger of pushing forward is the likelihood of shame entering the equation. There is not a shred of evidence that supports the use of shame to obtain a positive outcome. Shame is far more likely to lead a patient towards destructive and harmful behaviors. Additionally, the feeling of shame (“I am bad”), rather than guilt (“I did something bad”) often leads to blame-shifting and excuses. This brings us to the art of crucial conversations, a vital tool for managing any plan of care.

 

Listen to seek understanding

Former US Secretary of State Dean Risk stated, “One of the best ways to persuade others is with your ears – by listening to them.” This is the foundation of conducting a crucial conversation. The book Crucial Conversations: Tools for Talking When Stakes Are High outlines many different strategies for conducting crucial conversations and many are applicable to patient care. A key starting point is developing a shared pool of meaning. This is effectively accomplished with open-ended questions and listening (i.e. motivational interviewing). The goal of the conversation is not to “win” but to create a safe, healthy dialogue that leads to progress.

Prior to starting the conversation, gather as many facts as you can, without making negative assumptions. We then fill in any gaps through questions. Often, patients may assume that dialogue is decision-making when, instead, it is a process for gathering all relevant information. We can demonstrate our seriousness for dialogue by asking patients to share their story. We can share ours as well to facilitate a feeling of safety.

When approaching conversations about lifestyles (e.g. sleep, nutrition, physical activity), it is likely the patient has been a part of these conversations previously. This can result in the patient developing a thick set of emotional armor to protect themselves from shame and emotional discomfort. The answer is not to avoid the conversation or to attempt hammering though the armor, as these will only lead to disappointment and frustration for the clinician and pain and distrust for the patient. Instead, utilize the power of motivational interviewing and listen to create a safe environment that leads the patient to a willingness to listen to and employ your advice. I recommend reading Crucial Conversations for specific strategies and greater detail on enhancing your effectiveness with crucial conversations.

Bad Attitude

A final note before jumping into the lifestyle information. It is challenging to hold someone to a set of expectations and standards that differ from your own. This is not exclusive to leadership principles and professional conduct. If you always appear tired, snack on unhealthy food in the clinic, and have poor physical fitness yourself, it will be challenging to convey the importance of sleep, diet, and exercise to your patients. By no means is it impossible, but as stated early, people often seek to shift the blame or attention when they feel attacked or shame. This can lead to thoughts the patient may or may not express out loud along the lines of “if it is so important why don’t follow your own advice?”

Our actions frequently speak louder than our words and that applies to lifestyle education as well. This post will focus on sleep and I will cover nutrition (zero chance it will lead to any controversy…right?) and physical activity in the following two posts.

 

Sleep while you’re alive

I cringe every time I hear the phrase “I’ll sleep when I’m dead” and fortunately, that reaction is becoming more common. Over the past 5-10 years, sleep has been getting a lot more attention. While we may, for the most part, be past the days of “sleep is for weaklings,” proudly acknowledging how little we average on a nightly basis, sleep still falls far down the priority totem pole for many people.

Sleep can be divided into five stages – one with rapid-eye-movement (REM) and four without – which occur across roughly 90-minute sleep cycles. While REM sleep is associated with dreams, non-REM is the period for energy conservation and nervous system recuperation.[1] During non-REM sleep, our body releases hormones, increases the synthesis of protein, and mobilizes free fatty acids to provide energy. As you will see shortly, sleep has a massive impact on diet and exercise, recovery from injury, and cognitive performance.

There are two primary categories of sleep loss. Sleep restriction (SR) refers to a partial disturbance of their normal sleep-wake cycle. This is the milder category of sleep loss. Sleep deprivation (SD), meanwhile, refers to extreme cases of sleep loss, where both quality and quantity are significantly affected. It is important to understand the chronicity of SD as it will impact the time it takes to recover and normalize your sleep. Unfortunately, we cannot bank our sleep, and sleeping in late on a random Saturday will not erase chronic sleep debt. All of the impacts of sleep I am about to cover typically occur in a state of SD. SR may lead to some changes as well, but they are typically milder and can be quickly reversed or compensated for.[2]

 

Sleep influences our hormone regulation

Let’s start with some of the hard science and the reasons why sleep is so imperative. Sleep has a large impact on our control of anabolic hormones (testosterone, growth hormone (GH), IGF-1), catabolic hormones (cortisol), and ‘hunger’ hormones (leptin and ghrelin). Our glucose tolerance and insulin secretion are modulated by the sleep-wake cycle. Notice how the mix of hormones will impact both diet and exercise effectiveness. Additionally, sleep has a substantial impact on cognitive functioning. The changes in hormonal levels and cognitive functioning are impacted not only by the total duration of our sleep but the quality of our sleep as well.

Shorter sleep duration is associated with greater disturbances in these hormonal and metabolic variables. It has been well-documented that GH secretion is heavily influenced by sleep-wake homeostasis. Leptin levels – which directly affects feelings of satiety – are lowest when we are  in a state of sleep debt, signaling the brain an unnecessary need for extra caloric intake. Evening cortisol levels are highest when we are in a state of sleep debt and elevated cortisol levels can be detrimental to our ability to recover and build new collagen. HOMA (insulin resistance measure) levels post-breakfast are the highest in a state of sleep debt indicating a decrease in glucose tolerance and insulin sensitivity. As you can see, our sleep duration and quality can significantly impact the effectiveness of dietary interventions. I’m only getting started

 

Sleep influences dietary effectiveness

Insufficient sleep will lead to greater fat retention while stunting muscle development or potentially lead to muscle wasting. A study by Nedeltcheva et al. took two matched groups and controlled their diet (10% caloric restriction) and exercise to be the same. The only variable that differed was the amount of sleep they received: 8.5 versus 5.5 hours. At the end of the trial, each group lost the same amount of weight, however, the group that slept 8.5 hours lost a 50/50 fat to muscle ration while the 5.5 hour group lost a 20/80 fat to muscle ratio. [3]

During NREM sleep, anabolic hormones are stimulated which increases the synthesis of protein and mobilizes free fatty acids for energy production.[1] This method of preventing amino acid catabolism is inhibited in a state of sleep debt. We also see an increase in respiratory quotient indicating an increase in the utilization of glycogen stores rather than fat stores for energy.[3] In addition, insufficient sleep reduces circulating levels of testosterone and IGF-1 (anabolic hormones for muscle hypertrophy) and increases myostatin (inhibits muscle hypertrophy) and cortisol levels. We will dive into nutrition in the next post, but I wanted to highlight sleep’s direct impact on nutrition interventions.  Moving away from the nutritional side, performance and recovery implications are significant as well.

Sleep On Theraball

Sleep is not optional for recovery or high performance

Achieving a full sleep cycle is vital as each stage is a trigger for different physiologic events. Quick note, I will not discuss polyphasic sleep in this post, but it would challenge the notion of this necessity depending on the category you practice (e.g. Uberman or Dymaxion). Back to traditional monophasic sleep.

As stated, specific functions occur at each stage of sleep. For example, learning and motor memory, resulting from plastic reorganization within the brain requiring increased activation of the primary motor cortex, are associated with slow-wave sleep.[4] More specifically, it has been suggested that motor skill improvements are significantly associated with stage-2 non-REM sleep.[5] This is significant, as experiments have demonstrated substantial changes in learned motor sequence, need for conscious spatial monitoring, and emotional task burden when comparing volume and quality of sleep.[6] This is a wild guess, but I would assume improved motor output and more precise mapping of movements taught in the clinic would be of some benefit. However, sleep education should address both the role of sleep in performance and in recovery.

As mentioned earlier, SR and SD having different impacts on performance and recovery. For example, SR does not appear to affect single bouts of aerobic or strength performance. However, some evidence suggests sport-specific skill execution, submaximal strength, and muscular and anaerobic power decline following SR.[1] We may not notice a change in performance for a typical session, but the return-to-sport phase of a rehabilitation plan may point a spotlight on sleep deficiency. Furthermore, SR resulting from less than 7 hours of sleep can impair alertness, reaction time, memory, and decision making. Individuals report heightened levels of sleepiness, depression, confusion, and poorer overall mood states as well.[1] The negative mood states have been linked to over-training, thus making it imperative we are considering the sleep status of our patients.[7] Overall, despite the inconsistency in the evidence, it appears SR can impact the presentation of our patients in the clinic.

While SD has some conflicting evidence as well, there remains ample consistency and strength to signify SD can significantly impact athletic performance and recovery. SD increases metabolic demand, perceived effort, restoration of muscle glycogen, and increased sympathetic and decreased parasympathetic cardiovascular modulation.[1] The last point is of particular concern as disruptions in the sympathetic-parasympathetic balance are associated with overtraining.[8]

Expounding upon recovery, sleep plays a direct role in the secretion of GH and cortisol. Increased cortisol concentrations and blunted GH secretion results in an increase in muscle metabolism and a decrease in muscle protein synthesis. This less than ideal outcome would be detrimental to growth and recovery and potentially pain perception as well.[9] There is little doubt that SD has a substantial impact on cognitive performance. Greater total sleep loss results in poorer overall mood states, increased fatigue, sleepiness and confusion, decreased vigor and liveliness, heightened depression, and decreases in logical reasoning, coding, and decision making. Both the speed and accuracy of cognitive, auditory, and memory tasks are impact SD as well.[1] Suffice it to say, SD will dramatically impact the effectiveness of physical therapy.

So, in summary, when we in sleep debt, through poor quality and/or insufficient duration, we struggle to recover and heal, our cognition significantly declined, our regulation of glucose diminishes, and we are hungrier. Not good.

 

How much sleep do we need?

There is no universal number of hours. The typical range for adults is 7-9, for adolescents 8-10, and for young children 10-12.[10-12] Sleep duration varies depending on genetics, age, and stressors (e.g. activity level, job demands, stress levels, etc.). The best way to know how much sleep you need is to allow your body to wake up on its own. Yes, I mean without an alarm clock. An alarm clock should serve as a backup. Ideally, your circadian rhythm and routine will lead you to wake around the same time every day.

For example, I have not slept through the night past 7:15 in two years. Why is that? Because my 2-year old son has not slept past 7:15 his entire life. Now, I could easily go back to sleep (i.e. when on vacation sans Charlie), but those are one-off occasions. Our bodies are finely tuned, complex machines that know when they receive optimal sleep. Here comes the uncomfortable recommendation. If you wake up 20 minutes before your alarm goes off, that does not mean say a quick prayer of thanks and close your eyes for 20 more glorious minutes; it means get out of bed. Contrary to anecdotal experiences and common belief, the snooze button is not your friend. You are better off establishing a routine by going to bed and waking at the same time every day.

The true value of sleep comes from achieving deep slow-wave sleep and moving through the cycles sequentially as they trigger the hormonal releases. The extra 20 minutes are not truly helping and can impair your normal timing. Instead, set the alarm for when you absolutely must be out of bed by. If you wake sooner, then you are likely more well-rested (your body made the decision) and you have more time on your hands. Double Bonus. One final note on sleep duration, you cannot make up for sleep debt with one solid night of sleep. If you are in chronic sleep debt, it takes up to nine consecutive days of adequate quality and duration of sleep to recover.[12]

 

Sufficient hours is not enough

Snooze

Note that I have been referring to both quantity and quality of sleep. Simply lying in bed for 8 hours does not mean you received 8 hours of sleep. If you are tossing and turning all night, wake multiple times, or lie in bed for longer than 30 minutes before falling asleep, the quality is not great. You feel this when you wake in the morning. You know you are achieving adequate duration and quality of sleep when you wake without fatigue or the immediate desire for a gallon of coffee. So how do we achieve high-quality sleep?

There are many anecdotal answers to the question (type of mattress, number of pillows, etc.) but also many evidence-based recommendations. One of the primary needs is a dark room. Light triggers the timing of our sleep-wake cycle through melatonin release.[13, 14] We can go in-depth on the impact this has on night-shift workers, time zone, where you live, etc. but I will focus on the sleeping environment. The next is having either no noise or a “white noise” (e.g. a fan, a sound machine with repeating noise such as waves, rain, or actual white noise). For those who have put two and two together, yes, TV in the background is a solid ‘no-go’ for achieving good sleep. As much as you may think you are drowning out the noise (same goes for music), you have differing levels of cognitive function and awareness that challenges your ability to fall asleep and stay asleep. [15, 16] Outside the bedroom environment, you must consider the hours leading up to bedtime.

Thor

Avoid blue light as this too affects your circadian rhythm and timing of melatonin release. This means no computer, phone, or TV screens at least an hour prior to bed. Avoid caffeine at least 6 hours before bed (the caffeine half-life).[17] Avoid sleep aids (unless specifically prescribed by a physician, this blog is not intended to provide medical advice) and alcohol prior to bed as these impair sleep quality. While they may assist with falling asleep, they can alter our sleep cycles and impede our ability to achieve deep slow-wave sleep, however, some new drugs are attempting to improve slow-wave sleep. [18, 19] If consuming alcohol at night, it is best to have a moderate amount (e.g. 1 glass of red wine) with a meal as alcohol prior to sleep is associated with poor quality. [20]

Speaking of meals, avoid food consumption at least an hour prior to bed and avoid midnight snacks.[2, 11] I know, there are plenty of anecdotal experiences that fly in the face of several of these recommendations and the food one is potentially the straw the broke the camel’s back. Yes, going to bed hungry can be miserable and at times seem impossible. There are several issues with a meal immediately before bed going to bed:[21]

  1. Our insulin sensitivity plummets prior to sleep and during sleep (without getting into too much detail, this is a primary reason why midnight snacking is on the ‘do not do’ list) leading to increased fat storage and exacerbation of pain due to the spikes in blood glucose.
  2. Our body will be focused on digestion which can disturb our sleep quality.
  3. <eal timing can impact our circadian rhythm.

 

Integrating sleep education into a plan of care

Sleep With Computer

By no means is this an exhaustive list of the methods to positively influence sleep. Some readers may vehemently challenge a few of the listed strategies. A couple of notes on this. Sleep research lacks the robustness of other medical fields. There is conflicting evidence and we do not have a perfect understanding of sleep. Also, sleep is impacted by many individual variables such as genetics, stress, and demands of daily life. Some of the recommendations are unrealistic (night shift worker, a parent with kids who think sleep is more of a suggestion than a rule, living next to people who love randomly shooting off fireworks throughout the year, etc.) and have led to individual adaptations. Lastly, anecdotal evidence can often reign supreme. Bear in mind that “getting by” is not the same as optimal. Obtaining 8+ hours of sleep will come at a cost. It is up to you and your patients whether the added time dedicated to preparing for and obtaining optimal sleep is worth it.

Sleep is often overlooked and often the missing link to health, performance, and recovery. These recommendations will not yield immediate results. Like many aspects of health, it requires consistency to adapt. Be sure to convey this to your patients and encourage small steps in the right direction. These adjustments, along with nutrition and physical activity, can be the difference-maker in a successful versus unsuccessful plan of care.

 

References

  1. Fullagar HH, Skorski S, Duffield R, Hammes D, Coutts AJ, Meyer T. Sleep and athletic performance: the effects of sleep loss on exercise performance, and physiological and cognitive responses to exercise. Sports Med. 2015;45(2):161-186.
  2. Krause AJ, Simon EB, Mander BA, et al. The sleep-deprived human brain. Nat Rev Neurosci. 2017;18(7):404-418.
  3. Nedeltcheva AV, Kilkus JM, Imperial J, Schoeller DA, Penev PD. Insufficient sleep undermines dietary efforts to reduce adiposity. Ann Intern Med. 2010;153(7):435-441.
  4. Nedelec M, Halson S, Abaidia AE, Ahmaidi S, Dupont G. Stress, Sleep and Recovery in Elite Soccer: A Critical Review of the Literature. Sports Med. 2015;45(10):1387-1400.
  5. Nishida M, Walker MP. Daytime naps, motor memory consolidation and regionally specific sleep spindles. PLoS One. 2007;2(4):e341.
  6. Walker MP, Stickgold R, Alsop D, Gaab N, Schlaug G. Sleep-dependent motor memory plasticity in the human brain. Neuroscience. 2005;133(4):911-917.
  7. Coutts AJ, Reaburn P, Piva TJ, Rowsell GJ. Monitoring for overreaching in rugby league players. Eur J Appl Physiol. 2007;99(3):313-324.
  8. Achten J, Jeukendrup AE. Heart rate monitoring: applications and limitations. Sports Med. 2003;33(7):517-538.
  9. Haack M, Mullington JM. Sustained sleep restriction reduces emotional and physical well-being. Pain. 2005;119(1-3):56-64.
  10. Carskadon MA. Sleep in adolescents: the perfect storm. Pediatr Clin North Am. 2011;58(3):637-647.
  11. Halson SL. Sleep in elite athletes and nutritional interventions to enhance sleep. Sports Med. 2014;44 Suppl 1:S13-23.
  12. Kitamura S, Katayose Y, Nakazaki K, et al. Estimating individual optimal sleep duration and potential sleep debt. Sci Rep. 2016;6:35812.
  13. Gooley JJ, Chamberlain K, Smith KA, et al. Exposure to room light before bedtime suppresses melatonin onset and shortens melatonin duration in humans. J Clin Endocrinol Metab. 2011;96(3):E463-472.
  14. Nedelec M, Halson S, Delecroix B, Abaidia AE, Ahmaidi S, Dupont G. Sleep Hygiene and Recovery Strategies in Elite Soccer Players. Sports Med. 2015;45(11):1547-1559.
  15. Van den Bulck J. The effects of media on sleep. Adolesc Med State Art Rev. 2010;21(3):418-429, vii.
  16. Alkahtani MN, Alshathri NA, Aldraiweesh NA, et al. The effect of air conditioner sound on sleep latency, duration, and efficiency in young adults. Ann Thorac Med. 2019;14(1):69-74.
  17. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013;9(11):1195-1200.
  18. Roehrs T, Roth T. Drug-related Sleep Stage Changes: Functional Significance and Clinical Relevance. Sleep Med Clin. 2010;5(4):559-570.
  19. Kripke DF. Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000Res. 2016;5:918.
  20. Simou E, Britton J, Leonardi-Bee J. Alcohol and the risk of sleep apnoea: a systematic review and meta-analysis. Sleep Med. 2018;42:38-46.
  21. Wehrens SMT, Christou S, Isherwood C, et al. Meal Timing Regulates the Human Circadian System. Curr Biol. 2017;27(12):1768-1775 e1763.

ABOUT THE AUTHOR

Zachwalstonheadshot
Zach Walston, PT, DPT, OCS serves as the National Director of Quality and Research at PT Solutions. Zach grew up in Northern Virginia and earned his Bachelor of Science in Human Nutrition, Foods, and Exercise at Virginia Polytechnic Institute and State University. He then received his Doctorate of Physical Therapy from Emory University before graduating from the PT Solutions’ Orthopaedic Residency Program in 2015.  Zach now serves as the Residency Program Coordinator and the director of the practice’s Clinical Mentorship Program providing training for over 100 physical therapists a year.

Zach has numerous research publications in peer-reviewed rehabilitation and medical journals. He has developed and taught weekend continuing education courses in the areas of plan of care development, exercise prescription, pain science, and nutrition. He has presented full education sessions at APTA NEXT conference and ACRM, PTAG, and FOTO annual conferences multiple platforms sessions and posters at CSM.

Zach is an active member of the Orthopedic and Research sections of the American Physical Therapy Association and the Physical Therapy Association of Georgia. He currently served on the APTA Science and Practice Affairs Committee and the PTAG Barney Poole Leadership Academy.

Zach currently lives in Marietta, GA with his wife, son, and two dogs. Connect with Zach on Twitter, LinkedIn, and Instagram. To access more content on Living Clinically and resources on critical thinking and career growth, visit his website. You can also sign up for a bi-weekly newsletter to receive his latest blog posts, podcast episodes, research recaps, and recommended readings.