Stanford’s Fiona Barwick, PhD, on “Sleep Away Your Back Pain”

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have to point out the appropriateness of
my giving a talk on sleep at this time when a lot of
you are experiencing what is known as a circadian dip. Meaning you’ve been
awake for a while, you’ve built up
some sleep drive, and unfortunately
you’re alerting queues have dropped a bit. So I suspect a number of
you are feeling sleepy. I have to thank Dr. [INAUDIBLE]
for getting you up and moving because physical activity
is an alerting cue. So you’re probably
a little more alert than if you had not done that. We are actually creatures
governed by daily rhythms. Rhythms that influence when we
feel alert or sleepy, stronger or weaker, active or
quiescent, hungry or sated, across the 24 hour day. These rhythms govern our
biochemistry, our physiology, and our behavior often in
ways we don’t even realize. All living organisms experience
these circadian rhythms because all of life– from
plants to insects to fish to mammals– evolved
over millions of years to respond and adapt to the
changing light and temperature conditions in our environment. Circadian rhythms
allow us to maintain an internal representation
of our external world so that we can synchronize
our behaviors to that world and maximize our survival
and reproduction. Sleep wake is our
primary circadian rhythm. Sleep wake rhythms are
generated by light signals that enter the eye and
stimulate communication pathways between specialized
cells in the retina and the suprachiasmatic
nucleus, the master pacemaker in our brain. Pain can also have
circadian rhythmicity. Some of you may
already know this. Pain can be worse in
the morning and better in the late afternoon
and evening. Circadian patterns in
pain seem to be associated with alterations of the
hypothalamic pituitary adrenal axis and its cortisol output
along with changes in melatonin levels in the evening. Melatonin is our most important
sleep inducing hormone. So sleep and pain are
integrally related. Pain often disrupts
sleep leading to less sleep and lighter,
more fragmented sleep. And sleep disruption
exacerbates pain. In fact, recent research
suggests that sleep disruption is a stronger and more
reliable predictor of pain than pain is of
sleep disruption. So managing sleep is
crucial to managing pain. If you are losing sleep, your
threshold for and tolerance of pain is likely lower. Conversely, if you can
improve your sleep, you can reduce pain
frequency and pervasiveness. So what can you do to manage
sleep and consequently pain more effectively? You can do three things. First, prioritize sleep. Simple, but not easy. Do not– well make
sure you are not treating your biological
need for sleep with that cavalier
disregard that is so common to our culture. I can sleep when I’m dead. Yes, we can overcome the
imperatives of our biology to a certain extent. We do it all the time. But we do it at a cost. The cost for people
with chronic pain is more frequent
and widespread pain. To protect your sleep, put a
few basic strategies in place. First, make sure your sleeping
surface is comfortable, and your sleep environment
is dark, quiet, and the right
temperature for you. We tend to sleep better
in cooler environments, but that is not always true
for people with chronic pain. After that, set the alarm, if
you need to get up, and then turn the clock away so
you do not look at it if you are awake at night. Watching the clock
at night increases sympathetic nervous
system activity, which disrupts sleep,
and then worsens pain. Also make sure you create
strong, clear cues between bed and sleep. We are animals. And like Pavlov’s dogs,
we can learn to associate a neutral stimulus– such as
bed– with a more activated condition– such
as pain or anxiety. When this happens, bed is
no longer a cue for sleep. It is a cue for
conditioned wakefulness. So if you find
yourself awake at night for a prolonged
period of time, make sure you are awake
somewhere other than bed– a comfortable spot elsewhere
in your home, perhaps. If that is not an
option for you, if the bedroom is your
only refuge or you increase risk to yourself by
getting out of bed, make sure you
create signals that are associated with
wakefulness– like sitting up on top of the covers, lights
on– and signals for sleep– lying down under the
covers, lights off. So first prioritize sleep. Second, synergize sleep
and pain pathways. The same things that
can lead to better sleep can also help to improve pain. For example, being more
active during the day boosts your biological
drive for sleep and prevents muscles
from becoming deconditioned, too weak,
to protect your joints and body from pain. Of course, make sure, as you
are increasing your activity, that you do so in a responsible
way paying attention to how your body is responding. Allowing time to relax and
unwind before bedtime helps sleep to unfold more
easily and reduces sympathetic nervous
system activity that amplifies pain signals. What Dr. Karayannis
talked about before, the mindfulness
meditation, the breathing, the guided visualization
done in the evening, these can all help
sleep and pain. Catastrophic beliefs
about functioning are common in chronic
sleep and pain problems. I’m never going to be able to
function if it’s like this. These beliefs are often
extreme, usually inaccurate, and almost always unhelpful. Learning to think
about, and reframe, your ability to function in
the context of chronic pain or sleep disruption can
help both conditions. Finally, there’s some
interesting research suggesting that pain
might be aggravated by reduced light
exposure during the day, leading to circadian changes
such as increased melatonin levels at night. This raises the possibility
of using bright light therapy in the late afternoon to reduce
melatonin levels and pain signals. Conveniently, this would
also boost sleep drive because light is our
most powerful circadian sleep-wake cue. So you prioritize sleep,
you synergize sleep and pain pathways, and, finally,
you optimize, recognize and optimize, your own
circadian rhythmicity. We are all subject to the 24
hour light-dark environment in which we evolved. But we have adapted to that
environment in different ways. What you see here is considered
a typical circadian phase. But some of us, certainly
according to this, may feel naturally
sleepy at 10:00 PM, naturally
wakeful at 6:00 AM. Others of us however
feel naturally sleepy at 2:00 AM and naturally
wakeful at 10:00 AM. This normal, genetic
variability in circadian phase is called tau. Know your tau. Work with it. Sleep in it, if
you possibly can, because you will
always get your best sleep in your biologically
natural sleep window. Tau encompasses other
circadian rhythms in addition to sleep-wake. Learn what those rhythms are. Learn to recognize
your own rhythms– when you feel stronger,
more alert, less in pain. Match those rhythms to your
periods of rest and activity. And then, gradually, increase
the amplitude of those rhythms. Why? Because less robust
circadian activity patterns seem to confer a greater
risk for chronic pain and for cognitive and
cardiovascular problems. We seem to be the only
species that routinely ignores its biological clock. And yet, research shows
that internal circadian synchronization is vital
for health and well-being. In other words, if
you can make sure that your sleep-wake, rest
activity, and other circadian rhythms are synchronized
with each other and with your own
individual internal clock, you can achieve better
physical and mental health. And that will almost
certainly help with pain. Thank you. [APPLAUSE] I didn’t leave any
time for questions. I guess I do have some
time for questions. That’s so nice. All right, you sir. So the question was how
important is light to sleep? Light of course comes in
a range of frequencies from low to high frequency. High frequency light is
blue, violet, whites. Low frequency red,
orange, yellow. High frequency
light, blue light, the kind that is
emitted by any screen whether laptop or
tablet or phone or TV is equivalent, not in
terms of luminosity, but in terms of the frequency
is equivalent to daylight. We have specialized
melanopsin containing cells in our retina that are
sensitive to blue green light. These cells transmit
the signals to that suprachiasmatic nucleus. The light allows suprachiasmatic
nucleus to suppress melatonin. So when you are exposing
yourself to blue light, you are suppressing
melatonin levels. Melatonin is our sleep
inducing hormone. So if you’re suppressing
melatonin levels, you are not as sleepy. Conversely, if you put
filters on your screens which filter out that
blue light and convert it to red, orange, or
yellow light– this can be done with
tablets, computers, there are apps for this. There are glasses for this. You convert those daylight
similar cues to dusk type cues. Melatonin is thus
not suppressed. And you can watch TV
and still feel sleepy. Does that answer your question? OK. Yes. You sir. So how, if you’re thrown off
of your circadian rhythms, how do you get yourself back on. Well the first thing is to
figure out what is your tau. Now there is a test of what
is called dim light melatonin onset. Melatonin typically starts to
rise about two to three hours before natural bedtime. Natural bedtime is going
to vary for all of us. So if my natural
bedtime is 10:00, my melatonin will
start going up at 8. If your natural bedtime
is 2:00, your melatonin is going to start
going up at 12:00. These tests, unfortunately,
are still available mostly for research, not
for commercial purposes. But if you want
to know your tau, you can ask yourself
some questions. Does your sleep
during the week differ from your sleep on weekends? If you’ve ever had
a time in your life when you were able to go
to bed when you felt sleepy and wake up when
you felt wakeful, what did your sleep
schedule look like? And if you have the luxury
of sleeping for a week without having any
responsibilities, try it. Go to bed when you feel sleepy. Get up when you feel wakeful. That will be a good
indication of your tau. So the first thing you
have to know is your tau. Now not that all of us can sleep
in that biologically optimal sleep window. There are family
responsibilities, work responsibilities,
social obligations. So to a certain
extent, we are all able to reentrain
ourselves according to environmental
cues, those same cues that we evolved to respond
to light, temperature, physical activity,
social activity. The tricky part nowadays is
we are in a 24/7 environment where we have that
option, which is why we– alone among
species– routinely override our circadian cues. So you first have to
recognize your tau. You, then, have to
recognize that there are these circadian
cues available to help you reentrain. And then you have to start
sticking to a schedule. If you can sleep in your
tau, start doing it, and keep it consistent. The most important thing for
managing, maintaining that tau is the morning rise time. That’s when
everything gets reset. We are most sensitive
to morning light. So that’s when your
sleep drive gets reset, your body clock gets reset. So figure out your tau,
make sure you get up at the same time every morning. Make sure you synchronize
your feeding and fasting patterns, when you eat and
when you don’t eat, with that. So if you’re a morning
person with a 10:00 to 6:00 sleep schedule, have some
breakfast in the morning. If you’re a night owl and you’re
on a 2:00 to 10:00 schedule, don’t start eating until
11:00 or 12 when you get up. But make sure you eat meals
consistent with your circadian phase. I’m going to stop there. Well one other
thing I should say, if you’re talking about lighter
or more fragmented sleep, there are certain
techniques used with cognitive
behavioral therapy. Cognitive behavioral therapy
is a very flexible treatment. It can be used to treat
anxiety and pain, insomnia and depression. And there are techniques that
we use in CBTI, Cognitive Behavioral Therapy
for Insomnia, that would address some of
that sleep fragmentation that you’re describing. OK. Yes. AUDIENCE: You may have
just answered this. But you’re suggesting, then,
is you can retrain yourself in your circadian rhythm. FIONA BARWICK: Yes. We have evolved to
be able to do that. In fact, our typical
circadian phase is 24.2 hours. And our day is 24 hours. So every morning,
when we get up, we reentrain whether
we realize it or not. Yes. AUDIENCE: Yes. How about taking melatonin? A lot of friends use melatonin. It doesn’t work for me, but
what do you think about it? FIONA BARWICK:
Melatonin, remember, is this sleep inducing
hormone that’s released a couple of hours
before your natural bedtime. It really is not that effective
as a sedative hypnotic taken at bedtime because your
own melatonin has already been released. So it’s like putting
water in the pond. Doesn’t make that
much of a difference. However, if you have what is
called a delayed circadian phase, so you’re a night owl. You don’t feel sleep
until 3:00 in the morning. And you can’t afford that
because you have to be up at 8. Then, very low doses of
melatonin, taken five hours before bedtime are extremely
effective circadian phase shifters. You have to use
that in conjunction with dim light, bright
light, other things. But that’s how it is typically
and effectively used. Yes. Sleep can be one of
those things that is disrupted by concussion. And the more serious the mild
TBI, traumatic brain injury, is, the more serious
of sleep disruption. It’s not always an exact ratio. Some people can
experience what seems to be a mild concussion with
pretty significant sleep disruption. And other people,
that’s not a symptom. The best you can
probably do for that is continue with
physical activity, because that will help
to boost sleep drive, maintain a very
regular sleep schedule. And don’t get caught in what
can happen when people suffer from sleep difficulties,
which is start to extend your time in bed. That is actually the
worst thing you can do. I’m going to have to
stop there because we’re onto our next speaker. But thank you, very much. [APPLAUSE]


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