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

Persons with chronic low back pain (LBP) often require a lifestyle change 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. 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 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.”

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

Sleep and Sleep Hygiene

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. Sleep science tells us that sleep plays a vital role in the brain’s plasticity, the ability to adapt to input it received 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: depression, seizures, hypertension, increase in migraine symptoms, compromised immunity which increases the likelihood of illness and infection, and altered metabolism which can cause an otherwise healthy person to enter a prediabetic state after just one night of inadequate sleep.

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

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

Lifestyle Medicine, Sleep and LBP

"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

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.  This pain has been found to be closely related to the mechanism of central sensitization and low-grade neuroinflammation and is commonly associated with stress and/or anxiety.  Drug treatments are rarely effective for this type of pain management, therefore persons 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.”. 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.

A 2018 study by Elfering et al 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.

Psychological Well-being and Stress Management

Psychosocial well-being is a multidimensional construct consisting of psychological, social, and subjective components which influence the overall functionality of individuals in achieving their true potentials as members of the society. Psychosocial well-being incorporates the physical, economic, social, mental, emotional, cultural, and spiritual determinants of health. Well-being of an individual includes coping with the various stresses of everyday living and realization of the full potential of an individual as a productive member of the society. - UN Sustainable Development Goals

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

Lifestyle Medicine, Well-being and LBP

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.  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.

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.

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

COVID-19 and its Effect on Sleep and Well-being

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.

Bailly et al 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.

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.

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 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

Clinical tests and measures:

• The University of Pittsburgh Center for Sleep and Circadian Science provides tests and measures for insomnia, sleep quality, and a sleep diary for patient use. Free for use.

• 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:

• American Academy of Sleep Medicine
• American Sleep Association
• Better Sleep Council
• National Sleep Foundation
• American Institute of Stress
• American Psychological Association
• Benson-Henry Institute
• Stress Management Society