Sleep Well, Hurt Less


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Thankfully, more practices are adopting patient-centric, rather than practice- or staff-centric, orientations, meaning that patients’ comfort, healing and wellness needs are coming to the forefront instead of being seen as a luxury.

Specific examples include sure-footing surfaces for spinal cord injured patients and quiet music to support the healing process.

It may translate into adding cat towers and other feline friendly appointments, thick pads with clean, washable and soft cloths for the surface that allow for examination and treatment on the floor instead of only on cold, steel tables.

Such forward-looking practices institute measures that at the very least meet standard of care, such as controlling pain in a multimodal fashion so that patients can sleep. This typically requires individually tailored integrative and pharmacologic protocols that alleviate pain and address and/or prevent spinal cord windup.

Ensuring that an animal receives restorative sleep requires appropriate analgesia, not just tranquilizing them into a stupor to stop them from vocalizing in pain. The latter does little to protect the nervous system in a health-supporting manner.

Zzzzzzzzzzzz

Many of us experience the value of a good night’s sleep, especially after going to bed achy and tired and awaken refreshed, ready for a new day. Fortunately, sleep is finally receiving research-supported recognition for its role in replenishing the nervous system, regaining homeostasis, remedying dysfunction and relieving pain.

What happens when pain, stress, lights and noise rob us of the sleep our bodies need? Among many other medical problems, impaired sleep causes and exacerbates chronic pain.1 Almost 90 percent of people with such pain have problems sleeping.2

In humans, a dose-dependent association exists between sleep disturbances and the risk of developing ongoing pain in the neck, shoulders and low back.3 For hospitalized patients, pain and sleep disturbances often arise together as a result of invasive medical interventions4 with undermanaged pain from orthopedic surgery being some of the most common and profound5.   

How does the loss of even one night of upset sleep worsen both clinical pain and hyperesthesia?6
Sleep deprivation destabilizes endogenous dopaminergic and opioidergic analgesic pathways, predisposing patients to central sensitization and unremitting pain.7 Dopamine becomes important because it not only promotes and maintains states of arousal, it also modulates activity in key brainstem centers involved in both sleep and endogenous pain control.

Clinical research has shown that human patients with chronic facial pain and fibromyalgia demonstrate reduced dopaminergic levels and activity, illustrating the connection to pain problems.

Similarly, opioid peptides participate in both endogenous analgesia and sleep regulation, and opioid receptors appear in multiple brain centers that control both. Sleep deprivation also reduces basal levels of endogenous opioids, downregulates central opioid receptors and changes mu- and delta-opioid receptor function in mesolimbic circuitry.8

How Sleep Can Help

Sleep supports the nervous system in other ways as well. While sleeping, the brain “cleans house.” That is, the brain’s glial cell population (known as astrocytes) foster glial lymphatic drainage, leading to “glymphatic” fluid shifts. Glymphatic drainage serves as the brain’s housekeeping, homeostatic mechanism, along with parallel processes involved in cellular maintenance and recuperation from oxidative stress after periods of high synaptic activity.9 

Sleep gives the brain a chance to grow its glycogen stores. During this time, gene activity that facilitates neurotransmitter synthesis and transport shifts into high gear.

Concentrations of growth hormone and prolactin increase at this time, explaining why much of the body’s tissue repair and cellular growth occur overnight. Finally, sleep engenders memory consolidation and integration, emotional balance, metabolic regulation and hormonal normalization.

This is all vital for quality of life and, in some cases, survival.

Translating this to the clinical setting, practice owners can consider how sensory stimuli of many kinds help or hurt the healing process, including the opportunity to achieve restful sleep.

Many patients, whether human or nonhuman, have a hard time adjusting to the hospital environment.

Proactive modifications can lessen stress and facilitate recovery so that sleep loss, depression and pain will not further overwhelm their host defense systems and lead to immune compromise and homeostatic destabilization.

Hospital facility architects and interior designers could take into account ways to promote a patient-centered practice by attending to lighting, sound and patient comfort. Hospitalized humans lose touch with their natural circadian rhythm due to their exposure to suboptimal light levels around the clock.10

Even bright hospital lights during the day fail to equate with sunlight, while perpetual light exposure shortens and fragments sleep.11 This predisposes patients to mood disturbances and heightened pain.

Unpredictable activity and schedules may compromise sleep and upset circadian rhythms, accounting for worsening of a host of neuroendocrine, psychological and behavioral abnormalities.

Clinic changes may thus include exposure to bright light and more active music during the day with longer periods of dark (that still allow for attentive patient monitoring) accompanied by soothing sounds and/or music or quietude at night. 

Sleep is free, natural and safe. The return on investment for a sound snooze is therefore huge.

Before prescribing that next dose of tranquilizer for your howling postoperative patient, make sure you’ve controlled her pain, quieted the staff, played soft, slow music and instituted integrative analgesia.

No doubt, you both need the rest.

FOOTNOTES
Finan PH, Goodin BR, and Smith MT.  The association of sleep and pain:  an update and a path forward.  J Pain.  2013;14(12):1539-1552.
2 Finan PH, Goodin BR, and Smith MT.  The association of sleep and pain:  an update and a path forward.  J Pain.  2013;14(12):1539-1552.
3 Mork PJ, Vik KL, Moe B, et al.  Sleep problems, exercise and obesity and risk of chronic musculoskeletal pain:  the Norwegian HUNT study.  European Journal of Public Health.  2013;1-6.  doi:10.1093/eurpub/ckt198
4 Finan PH, Goodin BR, and Smith MT.  The association of sleep and pain:  an update and a path forward.  J Pain.  2013;14(12):1539-1552.
5 Medscape Neurology.  Undermanaged pain in the orthopedic surgical patient:  techniques to improve outcomes (slides with transcript).  Accessed at http://www.medscape.org/viewarticle/556201 on 12-14-13.
6 Finan PH, Goodin BR, and Smith MT.  The association of sleep and pain:  an update and a path forward.  J Pain.  2013;14(12):1539-1552.
7 Finan PH, Goodin BR, and Smith MT.  The association of sleep and pain:  an update and a path forward.  J Pain.  2013;14(12):1539-1552.
8 Finan PH, Goodin BR, and Smith MT.  The association of sleep and pain:  an update and a path forward.  J Pain.  2013;14(12):1539-1552.
9 Dresler M, Spoormaker VI, Beitinger P, et al.  Neuroscience-driven discovery and development of sleep therapeutics.  Pharmacology and Therapeutics.  2013; JPT-06620.  [Epub ahead of print.]
10 Bernhofer EI, Higgins PA, Daly BJ, et al.  Hospital lighting and its association with sleep, mood and pain in medical inpatients.  Journal of Advanced Nursing.  Jan.12282.  [Epub ahead of print].
11 Bernhofer EI, Higgins PA, Daly BJ, et al.  Hospital lighting and its association with sleep, mood and pain in medical inpatients.  Journal of Advanced Nursing.  Jan.12282.  [Epub ahead of print].

 

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