Why Don't We Sleep?
We all experience the odd night or two of poor sleep. For some this becomes a more regular occurrence, to the point of it being more regular than not. This is insomnia and people reach the point of dreading just thinking about going to bed, anticipating the repeated battle of tossing and turning most of the night. In discussing this with clients and other clinicians, the extent and effect of not getting a regular 8 hours sleep has clinically become apparent to me. Sure, you feel off your normal game if you miss a couple of nights, but if it is ongoing, the ramifications become much more serious. Take for example;
- Death/severe injury due to excessive daytime sleepiness
- Increased cardiovascular disease, for example, high blood pressure, CVA, AMI
- Poor/decreased memory, problem solving and other mental functioning
- Reduced immune system efficiency and greater infection rates
- Reduced healing rates and recovery from physical tasks
Pretty much all our of systems suffer when we do not receive the required sleep quantity and quality.Primary & Secondary Insomnia
The causes of insomnia (i.e., poor sleep quality and quantity) are divided into primary and secondary. Primary being factors related to the process of poor sleeping (e.g., napping during the day, too much coffee or working on a computer late in the evening) and secondary, resulting from some other pathology limiting the sleep process. It may seem intuitive that primary insomnia would be the more common of the two, and therefore management of insomnia would focus on improving a client's sleeping routine. A 2012 New Zealand primary practice study examined the causes of insomnia. Their cross-sectional survey included nearly 1000 participants of which 41% reported having sleep problems. The researchers used several different questionnaires to determine the causes of the insomnia. On drilling down into the results further, only 12% (95%CI: 9, 15) had primary insomnia. This equated to 45 participants, while the main reasons for insomnia were listed as depression, anxiety, restless legs, and sleep apnoea.
Don't get me wrong, it is very important to discuss with your client their sleep hygiene and bed time routines, however, more often than not the cause of their insomnia will be found in another domain. In my upcoming Sleep Right Sleep Tonight online course, we will explore how you can assess what is limiting your client's sleep and I will discuss evidence based strategies that you can use to help them overcome each problem. If you are interested we are offering a 40% discount on the normal course investment to those that express their interest here.
As I have come to better understand insomnia over the past 9 years, I have become more and more interested in the parallels with cLBP, but you could probably consider parallels with any form of chronic pain. We know that pain and insomnia influence each other. A poor night's sleep will increase pain sensitivity and predict new onsets of pain and that pain will disrupt and limit a person from experiencing a quality night of sleep. When examining and treating clients with chronic pain (i.e., > 3-6 months), using the bio-psycho-social model, two influential factors to consider are anxiety and depression. This could involve using available risk screening tools like the Orebro MSK Screening Questionnaire or the Hospital & Anxiety Screening questionnaire. It seems that when addressing secondary insomnia (i.e., chronic sleep disruption) that same is also true and anxiety and depression need to be evaluated. Also like chronic pain, I have noted that social factors contributing to insomnia are often multifactorial, of many layers and that it takes time to explore client's beliefs and fears associated with their insomnia. Like cLBP, there are usually no easy fixes, as the causes are rooted in personal habits and like cLBP, assisting someone to understand and work their way towards a goal of improved sleep is very rewarding.
I would be very interested to hear of your thoughts and experiences in managing insomnia in your clinic.