Welcome back to the Healing Pain Podcast with Dr. Katie Siengsukon
Sleep has an important role in our body’s functions. We spend one-third of our lives sleeping and in that time of sleep, our bodies become refreshed and re-energized. Kansas Medical Center Associate Professor Katie Siengsukon believes that poor sleep affects the immune system, tissue healing, cardiovascular health and can even be the cause of Alzheimer ’s disease. Learn why for chronic pain patients, addressing sleep issues is more important than addressing the pain issues. Better sleep means better health and lesser pain.
What would you think if I told you that you spend nearly one-third of your entire life sleeping? That quality of sleep is really important and specially having the desire or the sensation of waking up feeling refreshed and energized could be the most powerful, natural, and simplest way to lessen your pain. Despite the recognized health importance of quality sleep, between 50 million and 70 million adults in the United States experience a sleep disturbance and 63% experience sleep problems seven nights a week. Sleep has an important role in the proper functioning of nearly every system in the body and it has an important role in recovery, healing and of course, pain relief, one of the main things that we talked about here on the Healing Pain Podcast.
Here to talk to us about how better sleep can contribute to less pain as well as practical ways to assess and address sleep is Dr. Katie Siengsukon who is an Associate Professor in Physical Therapy and Rehabilitation Science Department and the Director of Sleep and Health and Wellness lab at the University of Kansas Medical Center. Her research focuses on how sleep impacts function, fatigue, cognition, pain and overall health. She also assesses the efficacy of non-pharmacological interventions including CBT-I which is Cognitive Behavioral Therapy for Insomnia to improve sleep. She has presented her research in education sessions on sleep topics at National Conferences including the American Physical Therapy Associations Combined Sections Meeting, the International Stroke Conference and the Consortium of MS Centers Annual Meeting.
Can Better Sleep Contribute to Less Pain? with Dr. Katie Siengsukon
Katie, welcome to the Healing Pain Podcast.
Thank you very much for having me. I’m very excited to be here.
I’ve been really interested to talk to you about this concept because I combine basic CBT-type principles to help people with chronic pain. I’m interested in talking to another physical therapist who has taken CBT under their wing but using it for another great way to help people with their health and their well-being especially their pain. I think the question to start off with is how did a physical therapist become so interested in quality sleep?
That’s probably the number one question I get asked when I first meet someone. I’ll give you the short version of a long story. It started back when I was a clinician. I graduated from physical therapy school and I was a full-time clinician in the clinic working with patients with various diagnoses and I was surprised at how many of my patients reported having sleep issues. To be honest, I felt really ill-equipped at what to tell them or what to do with them. I generally focused on positioning and comfortable positioning for sleep but that’s really about as far as I could really take it as far as my background and my education. I wasn’t really doing much and I definitely wasn’t doing any sort of formal assessment or any sort of formal treatment by any means. Then I started to think that I wanted to go back to do my PhD. At that time at the University of Kansas Medical Center, which is where I did my PhD, Dr. Lara Boyd was on the faculty and she is very interested in looking at factors that influence recovery after stroke. Where my interest in sleep fit in with her interest in promoting motor learning was at that time that there was a lot of evidence that at least in young, healthy people while you sleep, the connections that you make during the day gets strengthened so it can help you learn. It had never been studied in people with a neurologic condition.
It seemed like a really natural pairing between looking at sleep through learning but also promoting motor skill learning in people with strokes. That’s what really where I started in. I say that’s a very small topic looking at their old sleep and motor learning. Really the more I started to look into sleep and understand sleep, I really started to realize just how important sleep is for pretty much every body system. From pain modulation to immune function to tissue healing to cognitive function, which are a lot of processes that we as PTs are pretty interested in or at least want to make sure that our patients are having as best function and health as they can. It started me on this quest of learning about sleep and really getting the word out to PTs in particular but also healthcare providers specifically about what can we be doing in our clinical practice to better help our patients sleep? I think there’s ways that we can be assessing sleep and addressing sleep.
You have a Masters in Physical Therapy and then you have a PhD in Rehabilitation Sciences. As part of your PhD, did you begin to study that connection between sleep and motor learning? Did you go for formal CBT training somewhere along after that?
Really my research focus as far as my PhD was specifically on the role of sleep for motor skill learning in people with stroke. We had the individuals practice a computer-based tracking task. We had some people sleep in between practice and retention testing and some people stayed awake and the people of course who slept did better on the task without anymore practice but they just slept. That’s really what I did in my dissertation in. Then shortly after, I accepted a faculty position at the University of Kansas Medical Center. I’ve been on the faculty since 2008 and I received some funding from the American Heart Association to basically redo my dissertation study but in a sleep laboratory. I partnered with sleep neurologists at KU Med and had the individuals practice the motor tasks but sleep in the sleep lab overnight so we can actually look at what was going on in the brain and what were the different sleep stages and was there any association between the sleep stages and the motor skill learning; a pretty narrow focus as far as sleep and motor learning. I wanted to be able to not only study that relationship but I really wanted to get into how can we help people sleep better?
Being a physical therapist, I know there’s lots of evidence that exercise is important for promoting good sleep. We did a study in individuals with multiple sclerosis because that’s another common population of individuals who have sleep issues. We had some funding from the National MS Society. We randomized people into exercise group, a moderate intensity aerobic exercise group where they came to the lab three times a week, exercise for three months. We compare that then to what we had anticipated would be a control group, which was a stretching and walking program. It was intended to be low intensity. They still did it three times a week for three months but they did it at home. They did it on their own. I could hypothesize that the cardio-respiratory improvements of the aerobic group would be what would improve the sleep quality.
Lo and behold, when we analyzed the data both groups actually had improvements in sleep quality, which from a research perspective was hard. It was not only what I had anticipated but honestly from a clinical perspective, I don’t necessarily care which group had better sleep or why but the fact that they did. Wouldn’t it be so much easier if we can have the individuals with MS, “Here’s a stretching and a walking program. Do it on your own and you’ll still have benefits from sleep?” Now, the question is why is that? Going back and revisiting that, I’m just hypothesizing that for that stretching and walking group, most of them were doing it outside. They’re getting exposed to daylight, to sunshine. They’re getting out of their house. A lot of them are walking with a friend or a family member so there is that social support. Even though both groups had improvement, it was different mechanisms that were leading to those improvements. That was one thing that we did.
I just like learning new things. Being a PT, exercise was a natural thing to focus on. The more that I learn, I learned about CBT-I, Cognitive Behavioral Therapy for Insomnia and that really is getting at those behaviors and the environment, the cognitive processes that underlie insomnia and I thought, “If that was a more direct way to address insomnia complaints, I want to do that.” I went and I received some training through the University of Pennsylvania with Dr. Perlis. Now, I am using CBT-I. Right now, we were doing a study again in people with multiple sclerosis to look at the efficacy and CBT-I in treating insomnia symptoms in people with MS. I love to partner the exercise piece with the CBT-I piece because I think that’s really where we can see some really pretty tremendous benefits.
It’s so interesting because traditionally, CBT or Cognitive Behavioral Therapy has been in the realm of psychology. However, when you really pause for a minute and think Cognitive Behavioral Therapy, what we do as physical therapists, we’re giving people instruction that they have to think about and start to assess and from that, it changes their behaviors. In essence, what we do as professionals, and you can talk more about this as far as sleep goes, really is a version of CBT. We just may not have given it a title so to speak.
With the CBT-I, I know that’s a CBT specifically designed for insomnia issues, so there is the cognitive piece of it. For the CBT-I, it really focuses heavily on the behaviors and those behaviors like extending amount of time in bed and napping and getting off of the sleep schedule. It really focuses on those behaviors that I totally agree that we, as PTs, that’s in our wheelhouse. With adequate training, I really think something that PTs and other healthcare providers could be incorporating into their clinical practice relatively easily.
The term wheelhouse is a good term. I think I have a strong sense on nutrition. I help the APTA develop some really good language around nutrition. Now, it’s part of our scope of practice. When you say wheelhouse, I’m a little bit more vocal about things. I always say that I feel that basic CBT skills can be part of a physical therapist’s scope of practice. Behavioral change is the big part of what we do with patients and it’s extremely important to have to recover. Make the connection for us between sleep and pain and why it’s important. We talk to both clinicians on this podcast as well as the people who are looking for pain relief and solution. What is the connection between sleep and pain?
We know that a lot of people with chronic pain up to 90% have sleep issues. We know that a lot of people with insomnia, up to 50% have pain issues. We know that there’s some relationship between those. It’s thought to be that there is a loss of modulation of the descending inhibitory pathways that seemed to be what driving this perpetuation, this enhancement of pain in people who have sleep issues. I read that there was a clinical review that came out in 2013 and Finan was the author. It was this great clinical review about this bidirectional relationship that sleep causing pain or is it pain causing sleep and they reviewed some of the recent prospective and experimental studies. It was a great read and just fascinating that take-home message that really it’s the sleep issues that seem to be more important for driving the pain than the pain issue seem to be driving the sleep. I think that’s a very important message for healthcare providers and patients to know. Intuitively you think, “Of course if I’m in pain, that’s going to interfere with my sleep.” People don’t always flip it around as that it really seems to be that the poor sleep is actually what is predicting next day pain.
There has been fascinating studies that if you have poor sleep quality or have sleep disorders, you are at a higher risk of developing chronic pain conditions five years, ten years, fifteen years later down the road. I see this as an awesome opportunity for PTs, other healthcare providers. What if we could address these sleep issues early on? Could we potentially delay or even prevent the onset of somebody’s chronic pain conditions? If somebody is already having a painful condition, let’s focus on not only addressing that painful issues but also really the sleep issues because we know that they go so closely hand-in-hand together. I just think it’s a huge opportunity for healthcare providers and patients to really just consider how important sleep is. It really should be a high priority for everybody.
It’s definitely a topic that I think every practitioner should be aware of. I know you’ve written a good paper called Sleep Health Promotion: Practical Information for Physical Therapists. I think the information really is good for almost any practitioner because there are many practitioners that are seeing patients with sleep as well as chronic pain. I want to get back to some of the practical strategies for the clinicians. This is not a biology nor physiology podcast but can you breakdown a little bit the influence that when you’re not sleeping or you don’t have enough sleep, what systems of the body does it impact?
I like to say that it affects all body systems. I firmly believe it does but I usually caveat as well. It’s probably most systems because there has been some that have been better studied than others. We know that it influences the immune system. Many of your immune cells, they’re upregulated during the day or at night. If you’re not getting into a good state of sleep, that modulation gets lost and so you’re not producing immune cells that you should be to combat antigens so you’re more likely to get sick if you’re not sleeping well. We also know that sleep is incredibly important for tissue healing. Increase in growth factors and fibroblasts. If you’re not sleeping well, tissue healing is going to be interfered which again there are so many patients that we see that are recovering from symptoms from an injury.
We also know that it’s important for our cardiovascular health. If you’re not sleeping well, it’s very stressful in your sympathetic nervous system. It increases your heart rate variability and blood pressure variability, which then puts you to higher risk of cardiovascular disease. It’s incredibly important for cognitive function and various cognitive domains. Touched a little bit about motor learning and memory formation. It’s also interesting to think about a study that came out a couple of years ago. It was done in mice that showed while you sleep, you’re more likely to flush out the beta-amyloid that accumulates during the day in a mice model. Theoretically then if you’re not sleeping well, that beta-amyloid is going to stay in the brain, not getting flushed out, more likely to accumulate. We know that people who aren’t sleeping well are at a higher risk of developing dementia and Alzheimer’s disease down the road. Incredible opportunity for us to be intervening early hopefully prevents the onset of some of these chronic diseases. Poor sleep is also associated with increased risk of diabetes, increased risk of obesity. Pretty much most of our modern chronic conditions, chronic diseases have some role as far as poor sleep quality.
Sometimes clinicians have a hard time making that jump from a mouse study or a mouse model to practice. I think when you read a mouse study that says it affected amyloid plaque in their brain, you have to start to say, “Maybe I’ll pay attention to this one. It could be important for myself, my family, and obviously my patients.”
There had been some human studies that have used actigraphy and have shown that people with low levels of beta-amyloid that are so cognitively normal have poorer sleep quality compared to those individuals who do not have beta-amyloid or at least a certain amount of beta-amyloid in their brains. There are some human studies and I’m pretty sure that there’s a study going on that’s actually using some imaging in humans to be able to look at that flushing out of beta-amyloid. A study is going on but it’s not done yet. The data is not published but it’s the same thing that they saw in the mouse model that if you’re not sleeping well, the beta-amyloid is going to stay in your brain and put you to higher risk of Alzheimer’s disease.
If I’m a physical therapist in practice or another practitioner, what are some of the general questions I want to start to ask my patients on let’s say their initial evaluation or their initial intake?
I firmly think we should be asking all of our patients some just common sleep quality question. I usually start with, “How much sleep are you getting?” Not that quantity necessarily matters. I’m really more interested in quality but if somebody says, “I’m only sleeping five or six hours a night,” that gives me a clue that that’s something that we could work on. If they say they’re sleeping for seven, eight or nine hours and I know at least the quantity is there. I then usually ask, “How would you rate your sleep quality?” I think quality really matters because you could be sleeping for seven or eight hours, but if you’re having periods of apneas or hypopneas or restless leg movements, things like that or your sleep is really fragmented, you may be technically sleeping for seven or eight hours but you’re not getting good quality of sleep.
I think it’s also really important to ask how their current condition is affecting their sleep. Obviously if somebody comes in and they have had surgery for something or they have some sort of a musculoskeletal injury or they’re having a painful condition, that may very well be influencing their sleep or they could be saying, “I have this sleep issue before my condition started.” I think that frames how you might go about addressing things or at least evaluating the role of their sleep and how it might be affecting their condition. I also like to ask general questions just to get an idea of the risk for the three most common sleep disorders in adults: insomnia, sleep apnea and restless leg syndrome. I generally will ask, “Do you have difficulty falling asleep, maintaining sleep or waking up too early three or more nights each week?” That gives me an idea if they’re having insomnia issues and I usually ask, “Do you snore loudly or frequently? Has anyone observed you stopped breathing?” That’s definitely a risk of sleep apnea. Then you can also ask about restless leg syndrome to see if they are having uncontrollable urge to move their legs that’s been relieved by movement. Depending on how they answer those questions, I usually then will move into using an actual screening tool, more formalized screening tools.
Obviously if they say, “Yes, I have difficulty falling asleep, maintaining sleep or waking up too early,” then I’m going to move and do the Insomnia Severity Index because that gives a nice cutoff of ten or greater of risk of insomnia or I use the STOP-Bang to look at risk for sleep apnea. That way, I can know to refer those individuals for further testing. The same thing with the restless leg, if they have a high risk of restless leg syndrome, that’s something that I want to refer to a physician for further testing. Not to say that we still can’t be educating those individuals about good sleep hygiene and good sleep practices, but if you have sleep apnea and restless leg syndrome, chances are good that you need other treatment to address those issues.
Screening is the place where you start. You’re talking about screening then using really an evidence-based tool to go a little bit deeper. Then you’re talking about really sleep hygiene and then eventually down the road implementing CBT-I. Before we get to CBT-I, what are some of the hygiene principles that people can learn really relatively easy and start to use that in their practice?
The first really big one is maintaining a regular sleep schedule. Going to bed and waking up at the same time every single day. Even on the weekends, even on the holidays, even on your days off, every single day. That’s easier said than done but that’s one of the big things. Maintaining that regular sleep schedule really helps to entrain that circadian rhythm. That’s really key. The other really big thing is stimulus control. Meaning, if you are in bed, you should be sleeping. You want your brain to associate bed with sleep. The bed should be used for sleep and sex only. Everything else should happen outside the bed preferably even outside the bedroom. No watching TV, no reading books, no doing other things in bed. It all should happen outside. Those are two really key ones.
I think other things to think about is I get asked about naps a lot, “Can I nap?” I say, “It depends. Do you have difficulty sleeping at night?” If they say, “Yes,” then it’s like, “Then you really shouldn’t nap.” Having a nap decreases the sleep drive and you want a nice, high sleep drive so that you’re going to have a high likelihood of falling asleep successfully because you’re tired. You also want people to be safe. I don’t want anybody having accidents or anything like that so I say, “If you absolutely have to take a nap then by all means do that to be safe but limit it to 20 to 30 minutes and do that early in the afternoon.” You can build up sleep drive by the time you go to bed so you can fall asleep successfully. For people who have no problem sleeping at night and if you want to take a 20, 30-minute nap, sure. That’s fine.
The other things you’re obviously avoiding: nicotine before bed, alcohol is another thing to think about. I have some clients that like to have a nightcap which they’ll say, “It helps me fall asleep,” and I’m like, “It’s going to help you fall asleep but it’s going to disrupt your sleep. It interferes with your ability to get in and maintain that deep restorative sleep.” Cutting out alcohol is ideal. Obviously, watching caffeine is important. Getting regular exercise is also very important that helps to improve sleep quality as well. Thinking about the environment that you sleep in is also really important so you want a nice dark room. If you need blackout curtains or sleep with a mask on, making sure that your room is really dark because that light, it’s really critical to stimulate your brain to tell you that it’s time to be awake. In the bedroom, you want it to be dark. Blackout as much noise as you can or use a white noise machine or use earplugs. Think about your mattress and your pillow that those are comfortable, things like that.
You mentioned a lot of good lifestyle intervention. You started talking about some nutritional interventions. You mentioned caffeine, you mentioned alcohol. In your research, have you come across anything related to blood sugar dysregulation, which is oftentimes initiated with people who are diabetic and oftentimes people who are pre-diabetic or don’t even realize they’re on that spectrum?
There’s actually a PhD student right now in our program and that is his big area of interest. We have a faculty who does a lot of research in people with diabetes and specifically about exercise and improving glucose regulation and insulin production and all that stuff but he’s on the sleep piece. We have done some reading of literature and yes, sleep is important for glucose regulation, insulin, metabolism all those different things. There’s actually a pretty well-defined U-shaped curve. If you’re sleeping seven to eight hours, your risk of diabetes is much lower than if you’re sleeping less than seven hours or more than eight or nine hours. That’s definitely an area of interest in an area on possible research.
If someone were to go online, they listened to our conversation and they’re saying, “CBT-I sounds really interesting.” They go online. They start to read about it. They’re going to come across a concept called sleep restriction. When you first initially hear it, you think this is funny because we’re trying to help people get to sleep, but you’re saying they have to stand by their bed and make sure they don’t go to sleep. What is sleep restriction and how does that fit into the CBT-I model?
Sleep restriction is really restricting the amount of time in bed to where you’re going to be sleeping and knowing that it’s going to be a successful sleeping. Say you generally know that you can sleep really well for five hours. Generally, we want to restrict your sleep to a five-hour period and set that period of time again with a regular sleep time and a regular wake up time. You can set that circadian rhythm and we also then teach your brain that, “I can fall asleep really well. I’m tired. I’m associating my bed with sleep.” Obviously, we don’t want you to stay at five hours and probably you really wouldn’t even start at five hours. Most people will start at six or even six and a half hours because that’s what people are typically getting. Five would be on the extreme end. Then once they’re successful, if they have a sleep efficiency of 85%, that’s usually what I use with people with MS. I know in some other manuals will suggest 90% and above. Sleep efficiency refers to the amount of time that you are sleeping divided by the amount of time you spend in bed. You want to be successful sleeping 85% or above. What I use is 85% sleep efficiency. If they do, then I increase the amount of time in bed by fifteen-minute increments.
If they’re able to maintain falling asleep relatively quickly, they don’t have fragmented sleep, they’re still sleeping to their prescribed wake-up time, we then extend it another fifteen minutes. There is a little bit art to that, a little bit of training that goes into that. It is part of CBT-I. If you would go to a CBT-I course, you would have a lot of instruction on that, new case studies and all those things. That’s not necessarily something that I encourage PTs or other healthcare providers to implement without more training. That’s why I really focus for clinicians to think about their regular bedtime but sleep restriction is really a key part of CBT-I along with the stimulus control, which is something we can be doing as PTs and as healthcare providers.
Where would you like to see your work evolve in the future this combination of physical therapy and anti-insomnia so to speak?
I have several areas. I definitely have a passion for working with people with neurologic conditions. Right now my research is working in people with MS. If we can show that CBT-I is efficacious in people with MS, I would love to combine that with our exercise intervention as well. Combine exercise plus a sleep intervention, probably CBT-I would be one thing I’d really like to do. Another issue that I see is access to clinicians who are trained in CBT-I. I feel really strongly in promoting ways that we can increase access. There are some online programs or some apps that have been developed and web-based programs. IntellaHealth would also be an option so I see that being an area that I’d like to get into. We have a really well-respected neurologist at KU Med so we get people that come from all over the area, States away to come see her who then want to be in my CBT-I study but they can’t because they can’t come into the Med Center. I think, “There’s a whole group of people that would really benefit from more of a remote access to CBT-I.” That’s I think one place I’d like to go.
We’ve been talking for a long time with another faculty about combining her interest in chronic pain research and my interest in sleep interventions. That’s an absolutely natural place to go as far as doing CBT-I in people with chronic pain. Better yet, combining again either PT with sleep interventions or exercise and CBT-I in people with chronic pain is also an area that I see delving into. I think one of my big passion is really just getting information out to PTs and other healthcare providers that, “Here are the things that you could be implementing today in your clinical practice that will be having a very positive impact on these people’s lives and their quality of life and their health to developing tools that PTs can use and use easily and see. Here’s the decision algorithm on how to decide if somebody has a sleep issue and then refer them. Can we accurately refer the patients that need to be referred? Can we, as PTs, integrate sleep interventions into our practice?” If we could prevent the onset of these chronic conditions or delay the onset, I would say to follow people long-term, there are all sorts of things that we could be doing and I see a lot of application for it.
Especially when you think about how sleep affects every part of the body and every system in the body then you start to say, “There’s really almost endless application of sleep,” which I’m sure for you is super exciting. I’m glad you’re doing the research. It obviously shows that it’s useful and evidence-based and it’s useful in the clinical setting as well as the research setting. Katie, can you tell people how they can learn more information about you and the things that you’re up to?
I have a lab website. It’s SleepWell.kumc.edu. You can also follow me on Twitter, @KatieSleepPT. I’m pretty active. You’re also welcome to reach out to me via email. I’d love to discuss and collaborate and I’m always interested in finding PTs and other healthcare providers who get really rubbed up and energized to talk about sleep. If you’re one of those people, I’d love to connect and think about ways we could get this out to clinicians. Feel free to reach out to me.
It’s been great having Katie on the Healing Pain Podcast. At the end of every podcast, I always ask everyone to please give us a five-star review on iTunes and make sure to share this information out with your friends, family and colleagues. It’s great information that will benefit you, your family and of course, all your patients. I’m Dr. Joe Tatta, it’s been great being here with you this week on the Healing Pain Podcast. I will see you next time.
About Dr. Katie Siengsukon
Catherine (Katie) is an Associate Professor in the Physical Therapy and Rehabilitation Science Department and the Director of the Sleep, Health & Wellness Lab at the University of Kansas Medical Center. Her research focuses on how sleep impacts function, fatigue, cognition, pain, and overall health, and assesses the efficacy of non-pharmacological interventions including exercise and CBT-I to improve sleep. Dr. Siengsukon has presented her research and education sessions on sleep-related topics at national conferences, including the American Physical Therapy Association’s Combined Sections Meeting, International Stroke Conference, and the Consortium of MS Centers Annual Meeting.
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