Lifestyle Medicine, Sleep Hygiene and Psychological Well-being for Managing Chronic Low Back Pain

Original Editor - Stacy Schiurring based on the course by Ziya Altug

Top Contributors - Stacy Schiurring, Kim Jackson, Robin Tacchetti, Lucinda hampton and Jess Bell  

Introduction[edit | edit source]

Persons with chronic low back pain (LBP) often require lifestyle changes to effectively treat and alter their pattern of pain. When assessing these patients, it is important to fully investigate all potential pain aggravators to pinpoint the true source of their pain.[1] Applying the principles of integrative lifestyle medicine to physiotherapy practice encourages a more holistic assessment of a person’s LBP beyond musculoskeletal and postural assessments. A 2018 study by O’Sullivan et al.[2] states:

“lifestyle factors are known to be important in disabling LBP and to be involved with other domains. Sleep problems and disabling LBP are highly comorbid. Poor sleep predicts the development or worsening of disabling LBP, and disabling LBP predicts sleep problems. Sleep also influences other domains, such as psychological well-being/emotional distress. Disabling LBP may be linked to poor sleep habits and/or pain-disrupted sleep.”[2]

This page discusses the interconnection and relationship between sleep hygiene, psychological well-being and chronic LBP.

Sleep and Sleep Hygiene[edit | edit source]

People spend a quarter to one-third of their lives asleep. The American Academy of Sleep Medicine recommends adults get an average of seven or more hours of sleep a night, and the American Sleep Association recommends adults have seven to nine hours of sleep per 24 hours.[3] Sleep science tells us that sleep plays a vital role in the brain’s plasticity (i.e. the ability to adapt to input it receives during the day). Waste products are more efficiently removed from the brain during sleep as compared to during the day. Sleep also plays an important role in overall health. Lack of sleep has been connected to:[4]

  • Depression
  • Seizures
  • Hypertension
  • Increase in migraine symptoms
  • Compromised immunity which increases the likelihood of illness and infection
  • Altered metabolism, which can cause an otherwise healthy person to enter a prediabetic state after just one night of inadequate sleep[5]

Please read this Physiopedia article for more information on the science and principles of sleep.

Sleep hygiene, or good sleep habits[4] and education,[3] can help improve an individual’s ability to get good sleep.  Recommendations to improve sleep include:

  1. Consistent sleep and wake times every day, including the weekends[3][4]
  2. Create a sleeping area that promotes sleep: quiet, dark, and at a comfortable temperature[3][4] - avoid falling asleep to the radio, or television[3]
  3. Sleep in a comfortable, supportive bed area with a supportive pillow[3]
  4. Remove electronic devices, such as TVs, computers, and smartphones from your sleep area[4] and avoid their use near bedtime[3]
  5. Avoid large meals, caffeine, and alcohol before bedtime[4]
  6. Daytime exercise and physical activity improve your ability to sleep at night[4] and increase your daytime exposure to sunlight[3]
  7. Avoid intense exercise near bedtime[3]
  8. Embrace mindfulness at bedtime to aid in relaxation[3]

Please watch this short video of sleep scientist Matt Walker discussing ways to achieve better sleep.


Lifestyle Medicine, Sleep and LBP[edit | edit source]

"Insomnia is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep. You may still feel tired when you wake up. Insomnia can sap not only your energy level and mood but also your health, work performance and quality of life." - The Mayo Clinic[7]

Insomnia is common in persons with chronic pain, with 53% to 90% reporting a clinically significant degree of insomnia. People with chronic LBP are 18 times more likely to experience insomnia than the general population.[8] Chronic pain is related to the mechanism of central sensitisation and low-grade neuroinflammation, and it is commonly associated with stress and/or anxiety.  Drug treatments are rarely effective for this type of pain, so individuals with sleep disturbances caused by chronic pain are good candidates for physiotherapy led cognitive behavioural therapy (CBT). A 2018 systematic review states that “with additional training, physical therapist-led cognitive-behavioural interventions are efficacious for low back pain … cognitive-behavioural therapy for insomnia, as provided to people with chronic pain, typically includes education, sleep restriction measures, stimulus control instructions, sleep hygiene, and cognitive therapy.”[8] When comparing the effects of conventional and integrative exercises on insomnia and overall sleep improvements in older adults, tai chi has been found to be as effective as conventional therapy exercises.[9]

A 2018 study by Elfering et al.[10] found that difficulties with sleep seem to precede LBP and increased levels of work-related stress in working individuals and that sleep quality should be used as an early risk indicator. Insomnia is also an important predictor of impaired quality of life in people with LBP.[11]

The following video is a 15 minute guided Yoga Nidra practice. This form of yoga, also known as yogic sleep or effortless relaxation, teaches the practitioner to find the point of equilibrium between wakefulness and sleep.


Psychological Well-Being and Stress Management[edit | edit source]

"Psychological well-being is about lives going well. It is the combination of feeling good and functioning effectively. Sustainable well-being does not require individuals to feel good all the time; the experience of painful emotions (e.g. disappointment, failure, grief) is a normal part of life, and being able to manage these negative or painful emotions is essential for long-term well-being. Psychological well-being is, however, compromised when negative emotions are extreme or very long lasting and interfere with a person's ability to function in his or her daily life."[13]

Proper stress management involves maintaining an equilibrium between physical, physiological and/or psychological forces that could cause undue stress.[3]  Please read this Physiopedia article for more information on the impact that stress can have on health

Lifestyle Medicine, Well-Being and LBP[edit | edit source]

A 2016 study found both CBT and training in mindfulness meditation with yoga provided a greater improvement in pain and functional limitations compared with a person’s usual level of activity or care in adults with chronic LBP.[14] These improvements persisted for at least one year for both CBT and mindfulness-based stress reduction (MBSR), and for CBT for up to two years with continued integrative exercise participation.[15]

This video is a short discussion of CBT and MBSR treatments as discussed above by the lead researcher, Dr Daniel Cherkin.


A 2017 meta-analysis of 7 randomized controlled trials, involving a total of 864 patients with LBP, gives further support that MBSR may have a short-term positive effect on pain and overall physical functioning in adults, but suggests that further research is needed to compare MBSR against active treatments to better understand its role in the management of LBP.[17]

Please read this Physiopedia article for more information on how both conventional and integrative exercise can be used for stress management.

The following 7-minute video is an example of an adapted body scan meditation. This style of meditation is useful for stress management and allows the participant to feel each region of their body and release tension.


COVID-19 and its Effect on Sleep and Well-being[edit | edit source]

According to the American Psychological Association (APA), following the 2020 COVID-19 Pandemic “We are facing a national mental health crisis that could yield serious health and social consequences for years to come.” The APA’s annual 2020 perceived stress survey found that 78% of American adults surveyed report that the coronavirus pandemic is a significant source of stress in their life, and 67% report experiencing increased stress over the course of the pandemic.[19]

Bailly et al.[20] found reports that the psycho-social pressures during COVID-19 lockdowns, a decrease in physical activity, and ergonomic risk factors from working at home all had an effect on person’s with chronic LBP. Their 2021 study found that the majority of participates with chronic LBP reported unchanged or worsening LBP intensity during the COVID-19 pandemic.[20]

A 2020 article discusses the important role sleep plays in anxiety and stress management, and in supporting the immune system.  It points to integrative exercises such as yoga and meditation, to achieve better sleep and better prepare the body to withstand the stresses of living during this pandemic.[21]

Virtual reality (VR) offers an option for continued stress management and integrative exercises to treat chronic LBP during this time of social distancing. A study by Garcia et al.[22] found that the use of VR for cognitive behavioural therapy resulted in high user satisfaction and clinically meaningful pain reduction, and improvements in mood and stress for persons with chronic LBP.

Resources[edit | edit source]

Clinical tests and measures:

  • The Depression Anxiety Stress Scales (DASS) by the Psychology Foundation of Australia, shown to be reliable and sensitive for patients with back pain. Free to use, extra post for manual.

Suggested Organisational Websites:

References[edit | edit source]

  1. Altug Z, Introduction to Integrative Lifestyle Medicine.  Plus. November 2021.
  2. 2.0 2.1 O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. Cognitive functional therapy: an integrated behavioural approach for the targeted management of disabling low back pain. Physical therapy. 2018 May 1;98(5):408-23.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Altug Z, Lifestyle Medicine, Sleep Hygiene and Psychological Well-being for Managing Chronic Low Back Pain. Plus. January 2022.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 John Hopkins Medicine. The Science of Sleep: Understanding What Happens When You Sleep. Available from: (accessed 17/01/2022).
  5. Chaput JP, McHill AW, Cox RC, Broussard JL, Dutil C, da Costa BG, Sampasa-Kanyinga H, Wright Jr KP. The role of insufficient sleep and circadian misalignment in obesity. Nature Reviews Endocrinology. 2022 Oct 24:1-6.
  6. YouTube. 6 tips for better sleep | Sleeping with Science, a TED series. Available from: [last accessed 01/01/2022]
  7. Mayo Clinic. Insomnia. Available from: (accessed 17/02/2022).
  8. 8.0 8.1 Nijs J, Mairesse O, Neu D, Leysen L, Danneels L, Cagnie B, Meeus M, Moens M, Ickmans K, Goubert D. Sleep disturbances in chronic pain: neurobiology, assessment, and treatment in physical therapist practice. Physical therapy. 2018 May 1;98(5):325-35.
  9. Siu PM, Angus PY, Tam BT, Chin EC, Doris SY, Chung KF, Hui SS, Woo J, Fong DY, Lee PH, Wei GX. Effects of Tai Chi or Exercise on Sleep in Older Adults With Insomnia: A Randomized Clinical Trial. JAMA network open. 2021 Feb 1;4(2):e2037199-.
  10. Elfering A, Kottwitz MU, Tamcan Ö, Müller U, Mannion AF. Impaired sleep predicts the onset of low back pain and burnout symptoms: evidence from a three-wave study. Psychology, health & medicine. 2018 Nov 26;23(10):1196-210.
  11. Uchmanowicz I, Kołtuniuk A, Stępień A, Uchmanowicz B, Rosińczuk J. The influence of sleep disorders on the quality of life in patients with chronic low back pain. Scandinavian journal of caring sciences. 2019 Mar;33(1):119-27.
  12. YouTube. 15 Minute Yoga Nidra | Full Nervous System Massage. Available from: nLq3XR7YlLg [last accessed 17/01/2022]
  13. Huppert FA. Psychological well‐being: Evidence regarding its causes and consequences. Applied psychology: health and well‐being. 2009 Jul;1(2):137-64.
  14. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of mindfulness-based stress reduction vs cognitive behavioural therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. Jama. 2016 Mar 22;315(12):1240-9.
  15. Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-year follow-up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioural therapy or usual care for chronic low back pain. Jama. 2017 Feb 14;317(6):642-4.
  16. YouTube. Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy for Chronic Low Back Pain. Available from: nE9I8bLDhmc [last accessed 17/01/2022]
  17. Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H. Mindfulness-based stress reduction for treating low back pain: a systematic review and meta-analysis. Annals of internal medicine. 2017 Jun 6;166(11):799-807.
  18. YouTube. Mindful Meditation (Body Scan) - Integrative Health and Wellbeing. Available from: [last accessed 23/03/2022]
  19. American Psychological Association. Stress in America™ 2020 A National Mental Health Crisis. Available from: (accessed 17/01/2022).
  20. 20.0 20.1 Bailly F, Genevay S, Foltz V, Bohm-Sigrand A, Zagala A, Nizard J, Petit A. Effects of COVID-19 lockdown on low back pain intensity in chronic low back pain patients: results of the multicenter CONFI-LOMB study. European Spine Journal. 2021 Oct 4:1-8.
  21. Gulia KK, Kumar VM. Importance of sleep for health and wellbeing amidst COVID-19 pandemic. Sleep Vigil. 2020 May 4;4(1):49-50.
  22. Garcia LM, Birckhead BJ, Krishnamurthy P, Sackman J, Mackey IG, Louis RG, Salmasi V, Maddox T, Darnall BD. An 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality Program for Chronic Low Back Pain: Double-Blind, Randomized, Placebo-Controlled Trial Conducted During COVID-19. J Med Internet Res. 2021 Feb 22;23(2):e26292.