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

[00:01:34] Brett Neilson: If you're clinician out there looking for a simple tool you don't know much, um, about CBTI or what to do with your folks who aren't sleeping well, download the app, check it out yourself, and you can easily work with your patient or client through that process to help, uh, make some positive, uh, change.

If anybody's out there saying, well, I don't think that's within our scope, it absolutely is. And the A PTA, you know, gives us some really good, uh, guidelines on that.

[00:01:59] Mark Kargela: It's what it goes to, again, fit the, the treatment of the person in front of you. Not to like, this is my menu of stuff that I'm just going to impose upon you as a, as a, as a patient.

[00:02:09] Brett Neilson: It can be a source of anxiety. And if it is a source of anxiety, the wearable may not be the right fit for you.

[00:02:15] Mark Kargela: What is going on everybody and welcome back to another episode of the Modern Pain Podcast. This week we did something a little different. I wanted to take the podcast on the road. So I recorded at the Pain Science in Motion conference at Las Vegas this past weekend.

You're going to need to cut me some slack. I did record and I didn't realize till after I had spent an hour talking to Brett [00:02:34] that the recording of me was a bit blurry. So it bothers me. My OCD is struggling with it, but please cut me some slack. And again, this week we talked to Brett Nielsen. He's a colleague and friend.

He's been doing some publishing. He did a scoping review on the incorporation of sleep measures and research around chronic low back pain. He had some surprising results in his research as it really showed that we really don't take sleep into account when we're, Researching chronic pain conditions. We talked about that.

We talked about wearables and we basically talked about ways clinicians can use certain applications that are out there for free that you can use with your patients that are pretty easy to use. So this episode is full of good value. I think you're going to enjoy it again. Cut me some slack. Enjoy the episode.

[00:03:13] Announcer: #This is the Modern Pain Podcast with Mark Kargela.

[00:03:17] Mark Kargela: All right, Brett Nielsen, welcome to the first live. Modern pain podcast episode. It's good to have you joining us, man.

[00:03:24] Brett Neilson: Yeah, it's good. And good to be here.

[00:03:25] Mark Kargela: Um, we go back a little bit. We went, we did fellowship together. You were a little bit after I went through, but can you kind of introduce yourself?

[00:03:33] Brett Neilson: My name is Brett [00:03:34] Nielsen and I'm a physical therapist. Let's see, since 2009 graduated from university of Puget sound 15 year career now. I've done all sorts of different things from, uh, clinical practice to, uh, you know, running a clinic to running a couple large, uh, randomized controlled trials, uh, through some government, uh, grants in, uh, San Antonio area.

And most recently, I am a full time professor for the Hawaii Pacific University DPT program, which started in 2022.

[00:04:12] Mark Kargela: Yeah, and that's, that's a rough gig having to go out to Honolulu a few times a year. And your home base is where again?

[00:04:16] Brett Neilson: Yeah, home base is in Seattle, Washington. So yes, as you noted, I commute to Honolulu when I need to be on campus as it's a hybrid program.

So it's pretty fun.

[00:04:28] Mark Kargela: Yeah. And you're one of your content areas that you've talked about is sleep. That's a big part then. And probably a [00:04:34] topic that we're getting a little bit more commonly to discuss in PT. Can you talk a little bit about the research you've been up to in sleep and kind of what you're doing at the moment with that?

[00:04:43] Brett Neilson: Yeah, absolutely. So let's see. Gosh, December 2021. I've wrapped up a, uh, a doctor of science, uh, program. So this is like secondary, uh, more academic focused doctorate degree from Bellin college. And, uh, that was a great experience, but through that, I really got interested in sleep, uh, with one of my, you know, uh, colleagues who was going through the program, uh, Dr.

Mark Shepard, who you also know very well. And then, uh, one of our mentors was, uh, Dan Roan. Uh, Chris Dickerson was also part of our team there, one of the, uh, another fellow student. And yeah, we just got really interested in, in sleep and it actually started when we started thinking about, um, trials for chronic pain.

And there's so much evidence now out there that links sleep and pain together, right? So it's very [00:05:34] common if you're, um, Dealing with chronic pain, you're probably not sleeping well, and perhaps vice versa as well. If you're not sleeping well, you're more likely to be dealing with chronic pain. And so we started getting interested in, well, you know, all of these randomized controlled trials for chronic back pain as an example.

Um, you know, are they even looking at sleep, right? Are we missing a huge component to somebody's overall health and wellness? And in fact, we started digging into the research and realized, wow, there's five published guidelines for researchers who are conducting randomized controlled trials. And all five of these, you know, to varying degrees recommend the collection of a sleep disturbance measure specifically.

Um, and so we got curious about like, well, how many. Of these trials are actually following this, um, because we read a lot and we don't always, you know, see sleep showing up in the, in the literature. And so that was kind of one of the big projects that got [00:06:34] us started is, uh, you know, doing a scoping review.

[00:06:38] Mark Kargela: Yeah, I'm curious what, what, what you found in the review as far as when it looks at, because it's always interesting when you hear these, like, Guidelines of how we should be conducting research. And especially when it's the authority kind of areas of like the folks that are really the leaders of discussing sleep.

And then you, you do some, some digging to see, well, Hey, are these publishers or these authors utilizing what's been recommended? And what did, what did you all find with that?

[00:07:02] Brett Neilson: What we found is that, uh, the large majority, so we specifically looked at chronic low back pain trials, right? We needed to kind of zone in on an area that's highly researched to get a sample of like, is this happening?

Um, so essentially we were looking at all published trials for chronic low back pain and we narrowed in between 2010 through the end of 2022, which is when we wrapped up our analysis. And out of that, We identified [00:07:34] 282 trials for chronic low back pain, and these are not just conservative, you know, physical therapy trials.

These are pharmacological, surgery, um, and various conservative aspects from physical therapy to yoga to mindfulness, etc. Um, and out of those 282 trials, less than 10% Actually capture any measure of sleep and that may even just be like once at baseline or asking a specific sleep question So it's less than 10 percent there was 26 total trials out of 282 and then we essentially developed a like tool to kind of evaluate the Level of incorporation, right?

So like a score of one indicated that they collected sleep at baseline, but didn't touch it again, right? It doesn't show up any other time in the publication, all the way to a measure of four, which is a specific validated sleep disturbance measure. That, um, was captured at [00:08:34] multiple time points. So baseline and maybe the end of the study or at several others.

And that would have kind of been the optimal adherence essentially. And so out of that only 13 actually met the true like adherence to the guidelines, which is, you know, less than 5%. So there's a big opportunity here and it's not to call out any researchers, right? I mean, I think there's. That's I want to be really careful there as I'm a researcher myself.

And there's so much information out there that it's, it's tough. Um, also the amount of, you know, things that you have to collect, right. There's this survey fatigue. So you kind of have to, you know, what's most important to our aim, but there is a huge opportunity that if more trials were following the guidelines that we could better understand the link between sleep and pain, and maybe it's, you know, we're trying to treat the pain, but maybe we should be addressing the Sleep and or, and the pain will, you know, improve just as an example.

So,

[00:09:30] Mark Kargela: yeah. And I don't think anybody who's listening is going to be surprised that [00:09:34] when you don't sleep well, I mean, I think we can all probably relate to the fact that when you're under slept and you have kids, I have a kid and we've been through, we've been through the times where sleep has been a hot commodity as far as not getting much of it.

And I definitely can relate to just body in general, not feeling good and, and things. And it's, it's interesting when we have all this published data, how little that's been kind of. Peaked at, um, you've had the opportunity this weekend where the pain science and motion conference here in Las Vegas, Adrian Lowe's group and the pain in motion group from Belgium are putting on a great conference.

I don't know where it's going to be. It's going to be here or somewhere in two years. So, uh, keep your eyes on online with that. And we'll link Brett's study that he's speaking to online as well. Yeah. Um, but they talked about sleep in your, in your pre con. You did a full day of discussing sleep. I'm wondering any major pearls of, of wisdom that you got from that stuff that somebody who's listening, that's a clinician can kind of grab onto of, of some ways we can maybe intervene, examine, intervene with what somebody who's dealing with some [00:10:34] sleep challenges.

[00:10:35] Brett Neilson: Yeah, yeah. So I attended a full day kind of sleep workshop, if you will, or pre con yesterday with Niels and Celine from Belgium, and it was a fantastic session. Um, I think, you know, just, I guess maybe some big nuggets is that, you know, all of us can be involved in sleep. And if, uh, you know, those out there listening aren't aware, The American Physical Therapy Association has a specific position on sleep.

So if you just go to APTA. org, you type in, you know, sleep, um, it's one of the first things that's going to pop up there. And it very clearly identifies the role of the physical therapist. So if anybody's out there saying, well, I don't think that's within our scope. It absolutely is. And the APTA, you know, gives us some really good, uh, guidelines on that.

Um, so that's, you know, number one and you know, what was really presented was, you know, kind of a comprehensive approach, right? So what are, you know, some of the screening questions, right? So are we, [00:11:34] you know, it can be as simple as just asking your, your patients or your client that you're working with, you know, how are you sleeping?

Um, how long are you sleeping? And do you typically feel well rested in the morning? Um, those can be some really great questions. conversations to or some questions to start the conversation around sleep and help you as a practitioner decide, you know, is this something that I need to take note of that we maybe need to screen a little bit more in depth?

Or is there potentially an underlying problem here that again we need to refer on? Or is this something that we can address, you know, here in the clinic through some very simple, um, you know, sleep health education, some, uh, behavior modification, et cetera.

[00:12:16] Mark Kargela: There's a, I took a course recently. I was up at the Michigan PT association thing.

And there was a, did they talk about any apps? There's one, the CBTI, which I think is through the VA system. If I remember correctly, I'm not saying they use that from Belgium, of course, but Any tools out there [00:12:34] that clinicians, and we'll link the CBT I to folks who are list, who are watching this. Um, any tools or things that they've recommended or maybe ones you've come across too in your, in your studies and publishing a lot of great stuff on it.

[00:12:45] Brett Neilson: Yeah, so, uh, Nils and, and Celine, um, You know, apps are a little bit different in Belgium, but we did bring that up yesterday and discuss it. So, um, in fact, CBTI was like the, really the central focus of yesterday's, you know, pre con. And if you're not familiar with what that is, it's cognitive behavioral therapy for insomnia.

And insomnia is one of the, you know, top three, Um, sleep diagnoses that your patients may be dealing with, with, uh, sleep apnea and restless leg syndrome being the other two common ones. But insomnia by far as the largest, and it's the one that we can absolutely make a, uh, an impact on. Um, but yeah, so as far as like easy clinical tools, CBTI coach is fantastic.

Um, comes from the VA. It's a hundred percent free and it's, uh, recently went through an update too. [00:13:34] Um, so it actually now can like link up to any of your wearable technology, um, has a sleep diary in there. It has your primary measures. Um, so obviously, you know, there's the, um, PSQI, which is the Pittsburgh sleep quality index.

Um, you've got the ISI, which is another one, right? The insomnia severity index is probably the best measure for. Screening more in depth for somebody who's dealing with insomnia. And then one that's really interesting that we've actually used in a different research study is called the DBAS, which is the Dysfunctional Beliefs and Attitudes about Sleep.

It's a 16 question screener that really looks at maybe some of the uh, you know, misconceptions around sleep and some of the, like, maybe the maladaptive beliefs around sleep, like a common one is I need eight hours, right? If I'm not getting eight hours, I'm not getting enough sleep. But you know, we know that everybody needs a different amount of sleep, [00:14:34] right?

So, but you know, the kind of the. Society and the media really pushes this eight hour, you know, perfect window. Um, so that's embedded within the app as well. So if you're a clinician out there looking for a simple tool, you don't know much, um, about CBTI or what to do with your folks who aren't sleeping well.

Download the app, check it out yourself, and you can easily work with your patient or client through that process to help make some positive change. So,

[00:14:59] Mark Kargela: yeah, having just peeked at the app a bit, I haven't used it a ton with clients yet. It is definitely it's, it's well put together. It has, like you said, those integrations with wearables.

Uh, we talked a lot about wearables today in our pain science and motion course. Uh, we had, uh, uh, Matthew Smoak, who's a physician at the Stanford, uh, Medical system did amazing talk on that. I'm wondering if they talked about this and maybe if they didn't, what your thoughts are on it. Cause I sometimes, and I think I get this way too, where I almost get anxious about my sleep.

And I sometimes the more I get. Thinking about my [00:15:34] sleep and I have to do this about my sleep where I got it where it almost becomes like sleep Anxiety about me not sleeping and the more I kind of engage with some of that stuff Did they talk about that or if not again, was there anything that you've come across as far as that issue?

[00:15:48] Brett Neilson: Yeah, and that's, that's probably one of the biggest challenges with bringing more attention to sleep. I mean, it's a multi billion dollar industry. You just turn on the TV and you are getting ads for different apps or different beds or, you know, all of these different things to help you sleep better. And, um, and then also the societal pressures of like, what's the ideal.

And unfortunately, everybody is different. We all have kind of our own sleep signature, if you will. Um, kind of like a pain signature. That, um, you know, is unique to every single individual, so you can't compare yourself against somebody else. It's about finding what is the right Uh, thing for you, um, and what's working for you.

Um,

[00:16:31] Mark Kargela: Not to interrupt you, but [00:16:34] with that, how does somebody, if you come up with what's right for them, is it strictly like a subjective, like, Hey, I've been keeping track. This is how much I get. And I feel this way as I've kind of maybe journal, I'd take diaries and I kind of assess, like, especially if you're on Mer wearables, you might have metrics and things like that, that they're going off of.

Is there anything that helps somebody calculate, you Because of course, I mean, we can all go on Instagram and there's everybody and their brother who's got the answer of this is the exact amount of sleep that everybody should have. Um, any way that you found or heard in your studies and research that kind of helps somebody kind of narrow in on, Or, or maybe a physio or somebody clinician trying to help somebody neuron on what's the amount of sleep that's best for them.

[00:17:13] Brett Neilson: Yeah, this is a big key takeaway and I'll try to fuse that your previous question there too about wearables. Um, yeah, one of the big challenges that can cause it's a, can be a source of anxiety. And if it is a source of anxiety, the wearable may not be. The right fit for you. Um, it's really not intended to give you [00:17:34] data day to day, right?

I like to think of it as like zoom out, collect a lot of data passively, but maybe check on it once a week to kind of say, you know, how am I doing? And compare that against your own internal, you know, um, thoughts, believe, you know, feelings of like, how, you know, am I getting enough rest? Um, so that's kind of my approach to the wearables though.

All the wearables too, aren't super accurate. Um, and they, depending on what you're wearing, et cetera, there can be quite a bit of variability. So that's where. You could have a really great night of sleep and you pull up your app and you go, Oh man, I slept crummy. Right. And then that changes your perception on your sleep.

When in fact, you probably did sleep pretty well. And it was your wearable that wasn't positioned quite right or move too much, et cetera. Um, but yeah, so getting back on track, like what is right for For you as an individual, and this was something, you know, big nugget or takeaway from that pre con is quality of sleep is so much more important than quantity of sleep.

So we can almost throw the [00:18:34] number out the window and it has a lot more to do with the quality and just asking yourself, are you feeling well rested in the morning when you wake up? And, and we're not talking about like the minute you open your eyes, but like in that first half hour, do you feel like I'm ready to go.

I'm ready to start my day. You probably got a pretty good quality of sleep. Now, if you're dragging and you're like, Oh my gosh, I just having a hard time doing everything. I'm snapping at my, my kids or my family. I really don't want to get in this work thing. I'm about to type this nasty email, right?

You're probably didn't get a great night of sleep. And so kind of getting really good at just understanding where you're at, um, can give you a lot of. Insight into your quality, but if I can take that one step further, the big takeaway from this, uh, pre con yesterday is that you really want your sleep efficiency in that like 80 to 85 percent zone.

And what that means is it's the total time in bed compared to the total time asleep. So your time [00:19:34] asleep should be about 80 to 85 percent of your sleep. Your total time in bed, right? It's natural to be in bed and it to take 15 to even a 30 minutes to fall asleep. Um, and that would be part of your kind of awake time in bed and that's normal.

So 80 to 85%, if you're getting, um, you know, if you're well up in like the 95%, that probably means you need to increase the amount of time that you spend in bed. So you're giving yourself more of a sleep. sleep opportunity, right? Now, if you're on the other side and your, your efficiency is way low, you're probably actually spending too much time in bed and you want to restrict or shorten the amount of time you're spending in bed to achieve more of that 80, 85%.

Um, so just kind of some general ballpark. And again, I, that shouldn't be a source of anxiety, but if like you're in that kind of 80 ish window, you're probably doing pretty well. So.

[00:20:28] Mark Kargela: I like the thoughts of a big picture, 10, 000 foot view, maybe looking at it after a week's [00:20:34] collection. I, I, you know, it says the guy wearing an Apple watch and a whoop strap at the same time where I got Apple

[00:20:39] Brett Neilson: and aura.

So you're, you're equally guilty.

[00:20:42] Mark Kargela: Um, and I, you know, I do it for fitness and other means, not just sleep, um, to, uh, but I can definitely see how it becomes a source of, of anxieties for some folks and you get hyper analytical to the point. And I think it's important for us as clinicians, right, to, to recognize that patient.

I think we, and I see this in myself sometimes, anxiety over things. I have to just like, you know, put the phone away, put your whoop app down or put your Apple health app away for a little bit and just chill about it and not get so wrapped up in it. Cause my wife will roll her eyes at me then, Mark, you know, you're getting a little bit too hung up on this thing.

Um, and of course, you know, I want to live long and be there for the kids and all that stuff. I know you're in the same boat. Um, uh, you know, one of the things that commonly gets used and tossed around out there like mindfulness or like almost meditation type stuff. Where's your position and maybe where do you [00:21:34] think in clinical practice?

And again, maybe what you've learned. in your precon when it comes to utilizing those type of things as like part of your, your sleep kind of treatment of yourself or kind of sleep management program for yourself.

[00:21:47] Brett Neilson: Yeah, those can be great relaxation strategies, but I think that's the key is the relaxation strategy.

Um, so finding what works best for you to wind down in the evening when you're preparing for sleep. So, that could be You know relaxation or mindfulness or breathing activities. It could be simply reading a book. There's a fantastic research study that was done many years ago at the University of Sussex that shows that reading for about six ish minutes is great at like winding down like decreasing anxiety and um, uh, lowering heart rate, et cetera.

Um, but also, you know, sometimes TV gets the bad rap, right? And like you can't watch TV or, you know, limit the blue light before. Um, you [00:22:34] know, a half hour or an hour before bed, et cetera, et cetera. Um, but it, the research actually, and we talked about this yesterday in the pre con is that the research actually is maybe showing that blue light is maybe not as important as we thought it was, or maybe not as impactful as we thought it was.

So if watching TV helps you wind down in the evening, by all means, that's great. So it probably matters more of the content. Of what you're watching or even reading right if like you're into this book that you can't put down. That's probably not your best go to for bedtime Um, so yeah, it really doesn't matter as far as like if you're not into mindfulness or meditation, that's okay But that can be a great opportunity For helping wind down and reflecting on the day And yourself, just putting yourself in that present moment, right?

[00:23:23] Mark Kargela: Yeah, it's interesting, you know, and it's again, it's a patient by patient thing. You've got to fit the person in front of you. I just, you know, we get some, and it tends to be the, the highly testosterone driven male where, oh, I'm doing that [00:23:34] meditation stuff, this bunch of hokey stuff. And not everybody, you know, there's some folks that are very receptive to it in different things, but it goes to, again, fit the treatment to the person in front of you.

Not to like, this is my menu of stuff that I'm just going to impose upon you as a, as a, as a patient. Um, where do you think the barrier is? Cause I, maybe not barrier is the word, but you know, it's not been something, I don't know about you, but was sleep hygiene or sleep even discussed in PT school? I mean, maybe a few passing mentions, but for me and my PT training, I didn't get pretty much minimal about sleep.

[00:24:06] Brett Neilson: Yeah, no, that was not a topic. I'm not even sure, you know, even came up at once. Right. And I'm not sure I was sleeping super well through PT school. Yeah, exactly.

[00:24:16] Mark Kargela: I mean, you just think, I mean, it's always interesting. Like I've worked in a clinic that's in a unit at a university. So I see a lot of students and it's a fascinating study of like, when you are at your highest stressed, underslept, eating like crap, you know, the life of a grad student where, You know, we see all these pain issues and [00:24:34] stuff, um, go on.

So I guess it's interesting to see this stuff materialize in the populations that we serve as, as, uh, you know, academic, you know, faculty as well. Um, with that said, with, with the lack of it being introduced, I know you teach, you're, you're in academia and do things, uh, you know, I think you do some pretty good work.

Lifestyle medicine incorporations into your, into your teachings. Where do you think we need to go to help students kind of get, at least have a basic knowledge? Cause like you said, there's an app. You can get to where you're going to have pretty dang good resources at the, in the palm of your hand for a patient.

And again, you can, you can study and go, but is in your curriculum over there at HPU, is that something that you're incorporating some of that as far as sleep, at least educating students so they're prepared to, um, Have that discussion in that question that we spoke about with sleep.

[00:25:22] Brett Neilson: Yeah, it, it is. Um, of course you'd always love more.

Um, but yeah, it is, it is part of the curriculum. And in fact, we, um, bookend the curriculum. So, [00:25:34] uh, right in first term, they're getting health promotion and a fitness management course, uh, which does dive into nutrition and sleep and, um, you know, de stressing and, you know, um, Uh, avoidance of smoking and things of that nature, right?

So we kind of get into some of those like health components right from the beginning. Again, it's more of an exposure, um, and it's meant to, you know, get the, get the student thinking about the whole person, but also reflecting on their own behaviors and self. Um, we've had students in the past, right?

You've really struggled because they weren't self aware. They're not sleeping at all, right? They're just trying to do it all, and not prioritizing the right things. And we still need, even though you're busy, you still need the basic necessities of sleep, and proper nutrition, and movement. So we try to bolster that at the beginning, and then we teach a, uh, a two credit pain science course at the very end of the curriculum, which that gets, you know, fused into as well, now with more of the lens of, like, [00:26:34] how sleep is impacting, uh, pain, or playing a role in persistent pain.

[00:26:39] Mark Kargela: And what better time to learn some good sleep habits than when you're in graduate school where it is a tough go to get sleep. I just remember, you know, waking up at 4 in the morning, you know, 3, 3. 30 in the morning stressing about studying and not sleeping. And having those moments where I was just running on fumes and, you know, we see it in our students regularly.

Um, so yeah, I mean, a great case study of yourself as a, as a clinician, as a student, or as somebody who's, who's dealing with some sleep stuff to start working with this stuff, because again, I think the more we can kind of embody it in our own behaviors, the more easy it is to start educating your, your patients and your clients on, on maybe incorporating some of that stuff.

Um, where do you, where do you see. Sleep, any things that you got going on your plate that in as far as research, or I know you're doing a poster this weekend that is going to speak to, I don't know if it's speaking to your, your, uh, scoping review or if it's other things, but where do you see research or what, what's, [00:27:34] what's coming down the pipeline as far as maybe some ways that we're going to improve Maybe PT, um, and not just PT, because it's, it's, it's obviously PTs don't own sleep and nor should we, but it's definitely something that, as you've pointed out nicely, that the APTA has given us and people need it, right.

And we definitely are capable of having those discussions, but where do you think, you know, or I guess what, what things are coming on the pipeline for you, anything that you got going on research wise, and then. Um, if not, where do you think, um, sleep training needs to go as far as to get it to be a little bit more of a common thing that we're doing as a physical therapist or as a clinician who's dealing with people in pain?

[00:28:12] Brett Neilson: That's such a loaded question. Um, I think this, this, the simple answer is if more clinicians were interested in their patient or clients sleeping. Habits, like that already would be a big win because if you're able to at least screen for sleep impairments and refer those individuals to [00:28:34] a provider that can help them, even if you don't feel comfortable dealing with it, like right there, that can be a huge, um, you know, uh, success, right?

Or a huge opportunity for the person that you're working with. Um, but then I think it is very feasible for everyone to, you know, be informed about it. Yep. Yep. You know, some helpful behaviors that can help influence a better night of sleep and working with their patient to understand what they're doing and working with the client or patient to understand like what kind of changes they might be interested in trying, right?

Because it's not a one size fit all. And if you just start throwing your education out there about sleep, you're more likely to cause anxiety and frustration than actually getting, you know, moving the needle. So maybe choose one thing. Maybe it's just choosing a Wake up time, right? That's one of the most important things is getting up at the same time every single day within a half hour, right?

So maybe on the weekend you give yourself a little more flexibility with about a half hour, maybe our [00:29:34] maximum. Um, because then the time to go to bed and getting a better night's sleep will actually kind of come with that, right? Because if you have a crummy night's sleep, but you're getting up the same time.

Your sleep drive is going to be that much greater the night after and you're going to, you know, go to sleep very quickly and get a really nice solid night of sleep. So, um, I think that's, you know, kind of future what I hope for the profession is that we just get more comfortable with understanding sleep and talking about it.

Um, as far as, yeah. So this, uh, tomorrow I'll be presenting on the, uh, uh, scoping review that I've, I've covered and talked about, and then I have a, a poster on a, a secondary research study that I did with the same group, uh, Mark Shepard and, and Chris Dickerson and a few of our, uh, uh, professors, instructors at, uh, Bellin College, uh, Jody Young and, uh, Dan Roan and Eric Chaconis.

Um, but we actually, uh, The other thing in physical therapy, there's not great data on like how many of the people walking into our clinics are actually not sleeping well. So we essentially, um, we [00:30:34] employed, not employed, but we, uh, um, created an opportunity for fellowship students needing scholarly work and had them collect data for us in about 10 different states around the country.

And we collected data on, um, any patient coming into PT for a new evaluation for spine pain, so it could be thoracic, lumbar, cervical, um, and we essentially had them fill out a battery of, of things and one of them was the DBAS, that dysfunctional beliefs about sleep questionnaire, and then, um, looked at, like, how many people are showing up into the clinic with, who aren't sleeping well, and lo and behold, as you can probably imagine, uh, about half, and then, you know, two thirds of them are not getting great quality of sleep either.

Um, and then they also have dysfunctional beliefs about their sleep, which is strongly correlated. So if you don't have great beliefs about sleep, you're not sleeping well. The correlation Coefficient for that was 0. 7, which is really, really high and [00:31:34] the R squared is, is 50, you know, 0. 5, which really means that 50 percent of the factors that go into not sleeping well has to do with what you think about sleep.

Um, so that was like one of the big kind of take homes from. That, um, you know, study and that really kind of sets us up for future work on like, all right, so now we better understand maybe what some of these thoughts and beliefs are. Oh, and, and also how that's influencing pain. So then we looked at basically for every point higher on the DBAS.

which is a 10 point scale, your pain score is going up by a half point, right? So they're strongly related. So that just kind of sets us up for future research. We're, we're in the process of looking for some grant funding to do some intervention, uh, trials up at Ballin College.

[00:32:27] Mark Kargela: One thing I've heard, and I've had these concerns too because I think sometimes in the clinic when somebody's like in acute pain, right, they have an [00:32:34] acute, angry, sciatic issue where, you know, the clinician might say, well, let's just talk about your sleep.

And in that context, it's like the patient, you're kind of missing the mark a little bit. And that's probably an extreme example. So I think. Cause I, I bet, I'm assuming there's going to be straw man arguments of like, well, you're just like telling everybody to sleep. You're not even telling them that you're not even worried about their pain.

You think sleep is going to cure it all, which I know you and I know that all the researchers that you're involved with, that is absolutely not the case. But it's something that's an additive thing as you're still doing the good things that we do as physical therapists, chiropractors and others to help people manage pain.

So I'm guessing that you would envision. A program that might help people positionally from a mechanical. Can we put them in positions that help their pain, but also helping some of the. Sleep hygiene practices as well. So it's not like we talk about the sleep and just do a diary without focusing on pain.

Now, again, some people, when it's more of a chronic persistent thing, where it may be using some mindfulness where we're diverting attention away from pain might be a helpful thing, but, uh, [00:33:34] Um, is that kind of the thought you have too, as far as like, it's, it's part of a big picture of management, not like sleep.

And then to the detriment of addressing pain, cause I just want to address any comments that might hit us in the comments section here that people are going to tend to throw while you're just talking about sleep and nothing else. And what about the pain that they're dealing with? And, and well, if they're not sleeping, it's probably due to their pain, which is probably true to an extent for, for some patients for sure.

But some of these mindfulness things and different things, especially if you incorporate some of the acts stuff. Can help people have, you know, be, be able to experience pain and downgrade maybe be able to handle that Uncomfortable sensation being present yet still be able to drift off to sleep. What are your thoughts on around that?

[00:34:13] Brett Neilson: Yeah That's why I think we've got to get comfortable with Talking about sleep with our patients and clients because not to bring up another polarizing topic But I will in posture right so as we all know as physios like posture can be relevant in And important, right? Especially with the person who like comes in with the neck pain, they say, Oh, it hurts like this.

And [00:34:34] they're sitting in a super slouch position. You get them sitting up tall and they're like, Hey, that feels a bit better. Right. Posture is relevant in that, in that case. And so if you don't address the posture, you're probably not going to address the neck pain. Um, But in a lot of other cases, posture probably has nothing to do with why they hurt, right?

So, I think this is the same thing here where sleep might play a role, but it also may not. They may have been a crummy sleeper well before their pain ever started. And so, now is not the time to start trying to fix their sleep. because it's probably not relevant to what's going on, right? Let's address the pain thing first, getting moving more back to the things they want to do.

And then lo and behold, Oh, by the way, now, would you like to talk more about sleep? Right? That might be something that will help you enjoy life better, maybe prevent your pain from coming back. Right? So I think that's where we got, we have to get comfortable talking about pain and, and asking those important questions.

to understand is this relevant and is this something that [00:35:34] needs intervening now. But like you said, it's an adjunct. It's a component to the overall treatment package. And I think that's where I've seen the profession evolve in my, you know, 15 years of practice. When I got out, it was all about, The knee hurts, so we're just gonna focus on this part of the region, right?

And then we got into regional interdependence, and so we said, Okay, we gotta look at the ankle and the hip too, and maybe the back, right? And then, now we're like, progressed to, We've gotta look at this whole person, because this knee is attached to the hip. To a living, breathing, feeling emotional human being who may or may not be sleeping well, right?

So then we got to think about the whole person and what's going on with them and how this thing is affecting them And what's driving it? So you're absolutely right

[00:36:18] Mark Kargela: Yeah. Yeah, it goes on to like have a communication establish a relationship with a patient where you're you're talking You're not just like Going into sleep training because this little screening tool said they're not sleeping.

So you immediately dive into that you have a conversation You You get to their [00:36:34] narrative. You see, well, like you said, like if you talk to them and they haven't been sleeping for 20 years yet, this thing's just been going on for three. It may not be the lowest hanging fruit out there to start getting after, but I think sometimes, you know, we go on the course, we've all had that availability bias where, man, I just went on a sleep course and I'm going to go tackle everybody's sleep, whether they need it or not, you know, then that's where, you know, everybody, you go to your McKenzie course, your minute course, and everybody on Monday is getting it because that's just, you know, where you're at, your head's at.

No, I think that's a good way to go about it, just to kind of see the big picture of it. And I agree, it's refreshing. And I think our patients, you know, we talk to patients on the podcast and we, we, and I'm sure we all have patients in our practice who have conditions that are way more than just the knee, right?

And, and, uh, you know, our friend Joletta Belton always reflects back or often will reflect back on how she was termed the two o'clock hip, um, where we need to do better and we're doing better. And it's refreshing to see that, especially when patients. Have these complex issues that have been invaded much more than just their knee.

It's invaded their life and their relationships and their work and their [00:37:34] function in society and all the different things that we keep going on and on with, um, anything you think you've, you've brought some great points, of course, anything else you think we, we need to talk about as PTs or anything else, any other kind of.

Movements you think we need to make on the sleep when it comes to kind of imagine best imagine people in pain

[00:37:54] Brett Neilson: Um, I think the only other thing that comes to mind that I again I want it's like a slippery slope Do you want to be careful around is just because somebody has poor habits around sleep if they're sleeping?

Well And don't mess with it, right? Or if they're not interested in messing with it, they may have the worst behaviors, but they're getting a great night's sleep and feeling well rested in the morning. Like don't, don't mess with that, right? It's not a one size fits all. Um, so you, again, it just comes back to getting to know your patient or client, which we as PTs are set up so well to do.

And that's why I think we do play a critical role in, um, you know, in, in the realm of, The whole person, you know, and that includes, [00:38:34] you know, sleep. So I

[00:38:35] Mark Kargela: couldn't agree with you more, man. I just wanted to thank you for sitting down for the first live experience here. If there's any camera issues or any mic issues where you're going to chalk it up to take one that we've done this with, but, uh, it's been good to, to get to hang out with you here in Las Vegas.

We've been doing all study and no gambling, no anything. It's been all just a good, good nerding out on pain, but, uh, thank you for joining me today and thank you for all the good work you're doing.

[00:38:57] Brett Neilson: Yeah, absolutely. Thanks for having me.

[00:38:58] Mark Kargela: For those of you watching, we'd love to have you subscribe on YouTube.

Wherever you're listening to this podcast, we'd love to have you subscribe there. If you're dealing with difficulties, understanding where sleep fits in your practice or know somebody who's having difficulties fitting that into their practice, share this episode with them so that maybe they can kind of bump their practice forward, but we will all talk to you next [00:39:34] week.