Your patients spend 1/3 of their lives asleep, but if they can’t sleep, they can’t heal and recover
THE STORY IS ALL TOO FAMILIAR. Your new patient says they have difficulty falling asleep, staying asleep or waking up in the morning. They may complain of daytime sleepiness, trouble focusing at work or school, or even impaired driving. Worse yet, their frustration at trying to address their sleep issues through standard medical treatments has probably cost them even more sleep.
Regardless, you are now faced with a first-time patient who is exhausted, frustrated, and in no small measure, apprehensive about whether chiropractic can finally get them a good night’s sleep. How can you best help this type of patient, particularly if their sleep issues are the result of other health problems, such as chronic pain or chronic obstructive pulmonary disease (COPD)?
Let’s take a quick look at some sleep stats and standard medical treatments, and discuss the wide range of treatments DCs have available to help patients sleep better.
Sleep stats
According to the Institutes of Medicine, as many as 50-70 million American adults have some type of sleep disorder.,1 Insomnia is the most commonly reported sleep disorder, reported by approximately 30 percent of adults. Of these, approximately 10 percent reported suffering from chronic insomnia. More than 35.3 percent of adults reported getting less than the recommended seven hours of sleep during a typical 24-hour period. Finally, 48 percent of adult patients reported snoring at night.2
Pills and abuse
Standard medical treatment for sleep issues usually includes prescription or over-the-counter sleep medication. Most of these medications are classified as hypnotics, meaning that they make it easier to fall asleep, as well as extend the duration of sleep. Unfortunately, there can be adverse side effects, such as dizziness, light-headedness, and feeling drowsy or groggy the following morning. Furthermore, certain prescription sleep medications, known as benzodiazepines, can lead to dependence and abuse.
Benzodiazepines are particularly a concern, as they are often prescribed concurrently with opioids to treat certain types of chronic pain, such as that related to cancer. This combination of benzodiazepines and opioids can be an issue because both medications are designed to have a sedating effect. According to the National Institute on Drug Abuse, the number of adults who filled benzodiazepine prescriptions jumped by 67 percent between 1996 and 2013, from more than 8 million to more than 13 million. Given the rampant opioid crisis our country is facing, it is not difficult to see why patients are reluctant to take medication to treat their sleep issues.
CPAP machines
CPAP (continuous positive airway pressure) machines are often prescribed for patients with severe snoring or sleep apnea, in which they are unable to maintain positive airway pressure, and thus may temporarily stop breathing.
While CPAP machines can be useful for certain patients, they are contraindicated for those with breathing issues or certain pulmonary disorders, such as asthma or COPD. Furthermore, it can be difficult for patients to adjust to the feeling of the face mask, so compliance may also be an issue.5 CPAP machines can also be expensive and require a full sleep study beforehand.
It is important to remember that none of these standard approaches will necessarily treat patients’ underlying health problems, such as chronic pain, that may be causing the sleep issues as a result. Proper treatment requires the type of holistic approach chiropractic care can provide, as we shall see below.
A holistic approach
What do we mean when we talk about holistic medicine? Essentially, it means we are focusing on more than just one issue. If a patient comes to see you with a complaint of neck pain, do you just do a couple of adjustments and leave it at that? Of course not. You will look at the root cause, which could include improper diet, lack of exercise, potential stressors, an unhealthy environment, and a host of other factors. Once you have considered all these other factors, you can devise a treatment plan to do more than just treat your patient’s neck pain. Instead, your plan will guide your patient toward overall wellness.
This same approach works for treating sleep disorders. Given how prevalent sleep disorders are within the general population, you are well-served to consider that each of your patients has sleep issues, in addition to their chief complaint, particularly if it involves chronic pain. Ask your patients about their sleep quality and habits when you take their initial medical history at their first visit, and continue to track it during each of their appointments. This provides an easy benchmark that both you and your patients can follow to see how treatment is progressing.
‘Adjusting’ sleep
Of course, adjustments will be the foundation of any treatment plan to address sleep disorders. A 2005 study in the Journal of Manipulative Physiological Therapeutics reported the results from 154 patient interviews regarding their experience with chiropractic adjustments to treat their sleep issues.⁶ One-third of the patients said they noticed a change in their sleeping habits almost immediately. Furthermore, all but one of these patients reported a positive change.
Patient pillow (and mattress) talk
Your patient’s pillow is the easiest factor to overlook in terms of poor sleep, yet is the simplest to solve. A pillow that does not provide proper support for the neck and head can easily lead to snoring and, if not corrected, eventually sleep apnea. The standard pillow sold in most stores really does not measure up when it comes to providing proper support.10 In comparison, a properly supportive pillow will keep the neck and spine in alignment to reduce neck and shoulder pain.
Thijs van der Hilst, CEO of Pillowise, suggests that the best pillow for your patients is one that not only provides proper support, but is also properly sized to their head and neck.
“An appropriate pillow that is the correct height and shape will adapt to the contours of your neck, is comfortably soft, and gives great support,” he says. “To get the best possible rest, and for your muscles to be at their most relaxed, it is important that you sleep on a pillow that is tailored to your dimensions.”
Van der Hilst also suggests that these pillows can be part of an overall chiropractic care program to improve patients’ sleep habits. He recommends combining measuring patients for the proper pillow along with education about how to improve general sleep habits. Having patients track changes in their sleep can also be an excellent way to motivate them to continuously improve their sleep habits.
Mattresses
Mattresses are another important consideration for chiropractic patients in the sleep science realm. Technology over the past 10 years has bolstered the mattress industry to new heights of comfort and support for aches and pains.
Patients can choose from memory foam, innerspring beds, air and gel mattresses, organic beds, covers and fabrics that studies have shown promote better rest, transitional layers that can target specific pain points such as lower back, and technology such as cooling, push-button firmness control, and head regions that can be raised and lowered.
iSleep is one high tech offering with dual air chambers making for adjustable firmness on both sides for two sleepers, a Comfortsense-patented innercoil design, pressure-relieving foam, and adjustable therapeutic warmth. iSleep has been working exclusively with chiropractors since 1999. Co-founders Lynn and Ron Larson in 1988 built one of the world’s first sleep research laboratories with the assistance of sleep research pioneers at Nebraska Wesleyan University to study what makes quality sleep and how a mattress can provide that.
“We learned what is important for quality sleep and for extending a chiropractor’s care in the eight hours a patient spends in bed,” Larson said. “A bed that supports the sleeper in all of the stages of sleep is paramount. No two people have the same requirements and an air bed provides perfect comfort for all sleepers. However, an air bed, or any bed, must have differentiated support to prevent sagging. The iSleep bed is custom built for each sleeper to provide support for a neutral sleep posture at any firmness setting. Memory foam, springs, and gel alone cannot do that.”
Natural supplements for sleep
Cannabidiol, which is one of the two active chemical compounds in cannabis plants, has been the subject of several intriguing studies for its analgesic properties, as well as its potential for treating both sleep apnea and insomnia.
A 2017 literature review study, published in Current Psychiatry Reports, provided a round-up of the current research on the value of CBD for sleep disorders. The literature shows that CBD has benefit for both sleep apnea and insomnia. It may also improve REM sleep and reduce daytime sleepiness. In terms of addressing underlying health issues that can impair sleep, CBD also may reduce both chronic pain and nightmares associated with post-traumatic stress disorder (PTSD).7
Your patients may have concerns about the potential psychoactive properties of CBD, as it is similar to the psychoactive tetrahydrocannabinol (THC) compound, which is also found in cannabis plants.7 CBD works on the CB2 receptor and does not have psychoactive properties, while THC works on the CB1 receptor. There are two separate varieties of the cannabis plant, each of which has more of one compound than the other. The hemp variety contains much more CBD, so is used for medicinal purposes, while the marijuana variety contains more THC and is often used recreationally or for advanced chronic pain issues.
Melatonin has a solid body of research showing the benefits of supplementation for synchronizing circadian rhythms and improving overall sleep quality. The brain’s pineal gland produces this hormone only at night, and it works with the circadian rhythm, telling the body when it is either night- or daytime. A 2017 article in the journal Neurological Research reviewed the state of the research on melatonin.8 While standard sleep medications may be effective, they come with undesirable side effects, most notably the risk of dependence.3,4 In comparison, melatonin supplements may be as effective in treating a variety of sleep disorders, but with significantly fewer side effects and no noticeable risk for dependence or addiction.8
High-tech sleep
While most of the treatments DCs use to improve sleep have been available for years, there are also some exciting, high-tech approaches that take advantage of the latest neurological research.
A good example of such an approach is technology that helps rewire the human brain to promote better sleep by reducing stress and pain. One interesting avenue of research for doing just this is what is known as brain entrainment. It uses a series of pulsing sounds or lights to stimulate the brain into the full cycle of frequency waves, from beta, to alpha, to theta, to delta.
Patrick K. Porter, PhD, developer of BrainTap, is using just this type of neuroscience to help people retrain their brains in order to help them sleep better, be more creative, learn more efficiently and reduce pain, among other benefits.
“BrainTap uses an app that you can download and use with our headphones,” he says. “It takes your brain from the beta brain, through to the alpha and theta waves, where your brain learns, to the delta waves during sleep, and then brings you back up to beta.”
Although this technology works somewhat similarly to meditation or guided imagery apps, Porter explained that such apps usually only go as far as the alpha wave level, which are the areas of enhanced creativity. His program goes further, in order to promote healing and better sleep.
Porter is conducting several studies of this technology, including one with students at Duke University. He explained that a college student population is ideal, as they are often stressed and low on sleep. Initial results appear to indicate that the students are better able to retain knowledge by using the BrainTap technology.
Another ongoing study in Brazil with computer programmers who tended to stay awake until 2 a.m. showed that they were more likely to go to bed around 11 p.m. after using the app. Porter is also collaborating with a chiropractor to incorporate BrainTap into chiropractic care, with promising results so far.
That new patient who cannot sleep trusts you to help them get better rest. Fortunately, you have a wide array of therapeutic options from which to choose to get your patients back on track to getting back into bed for a good night’s sleep.
Tina Beychok is an editor and writer with expertise in technical, academic and scientific materials. She is a regular contributor to Chiropractic Economics and resides in Long Beach, Calif. Her online portfolio can be viewed at thatwordgrrl.com, and she can be contacted at tbeychok@gmail.com.
References:
- Institute of Medicine (US) Committee on Sleep Medicine and Research. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academies Press: 2006.
- American Sleep Association. Sleep and sleep disorder statistics. https://www.sleepassociation.org/about-sleep/sleep-statistics/. Accessed March 17, 2019.
- Cleveland Clinic. Sleeping pills. https://my.clevelandclinic.org/health/drugs/15308-sleeping-pills. Updated March 15, 2017. Accessed March 18, 2019.
- National Institute on Drug Abuse. Benzodiazepines and opioids. https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids. Updated March 2018. Accessed March 18, 2019.
- National Institute on Drug Abuse. Benzodiazepines and opioids. https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids. Updated March 2018. Accessed March 18, 2019.
- Pinto VL, Sharma S. Continuous positive airway pressure (CPAP). StatPearls. Jan. 20, 2019.
- Jamison JR. Insomnia: Does chiropractic help? Journal of Manipulative Physiological Therapeutics. 2005 Mar-Apr;28(3):179-186.
- Babson KA, Sottile J, Morabito D. Cannabis, cannabinoids, and sleep: A review of the literature. Current Psychiatry Reports. 2017 Apr;19(4):23.
- Xie Z, Chen F, Li WA, et al. A review of sleep disorders and melatonin. Neurological Research. 2017 Jun;39(6):559-565.
- Franceschetti M. Why technology is the future of sleep. Forbes magazine.
