Nap Club

"When you have insomnia, you are never really asleep, and you are never really awake". 

- Chuck Palahniuk, Fight Club

I cannot help but be extremely jealous of my four-year-old nephew. That kid has no idea how good he has it. Sure, his life in general is pretty scheduled (like us all), but within that schedule is a designated nap/rest time (it's called "rest time" because if you mention nap, he will freak out. Rest time always turns into naptime). I told you that he has no idea how good he has it. He gets a nap planned into his day, and he takes it for granted! I would do many things to get a designated nap time scheduled into my 9+ hour work day, just 20 minutes that all I ask! In fact, if I were president, I would change the typical 1 hour lunch to a 30 minute lunchtime (let's be real, half hour is enough time for lunch if you plan ahead and make one) at 11am, and a 30 minute nap time at 2:30pm. VOTE FOR ME.

In fact, there are a couple large corporations that do allow "naptime". Nike Headquarters in Beaverton, Oregon have a designated Quiet Room that is intended for expecting mothers, however it is available to anyone on campus. They just have to check out the room when they want to use it. I have no idea what this room looks like, but I'd imagine it's a lovely oasis for quick R&R. Google Headquarters in Mountain View, California have nap pods on there campus where employees can escape to relax, listen to soothing, and even get some shut eye. British Airlines and Continental pilots making international flights commonly take turns practicing “NASA naps” since they know sleep is crucial for alertness and overall wellbeing. Yes it is great that these rest options are available however unfortunately, it is not used often. After inquiring about the nap rooms from a close friend that works for Nike, the quiet room hardly gets used. This is most likely due to the stigmas associated with resting, such as laziness, lack of ambition, and having low standards. This could be one reason why naps aren't common practice. 

What are other reasons that naps aren't more of a common practice? One could argue that it takes away from productivity since employees are away from their work desks. And others may say that naps are good for children since they have growing brains (and they will be super grumpy if they don't!), not necessary for adults. I'd argue that I would probably be less grumpy if I had a naptime too. But studies are showing that just a 20 minute nap can help boost the brain... it improves memory, concentration, and overall improvements in quality of life.¹ When I say nap, I mean a cat nap at some point in the afternoon since around 2pm is when the body's circadian rhythm (natural clock) is at it's lowest point of alertness. So sure it may not be common practice in today's work place to take a quick siesta, but maybe it should be, or at least have a half hour to relax, meditate, listen to soothing music, take a T.O. for the brain. Sure as we get older we are able to concentrate for longer periods of time, but no person is able to concentrate on one task for 8 hours straight. And as we get older, we have a lot more pressures than we did as kids. We now have a family to feed, a house to pay off, we are drowning in loans, and there is your parents that you have to now look after. We are freakin' exhausted, all the time.

So is this better than have half awake zombies sleep walking around the office trying to make decisions and deadlines? The good news is that people still show up to work when they are tired, but the truth is that they are much less efficient. A 2011 study on insomnia surveyed 7,428 full-time employed people asking questions dealing with sleep habits and work performance.² Of those individuals, nearly 25% were estimated to suffer from insomnia (younger/middle aged women were most affected by sleeplessness compared to men and employees > 65 years of age). This study also estimated that insomnia costs the average America worker 11.3 days of work, which is $2,280 in productivity losses. This totals to $63.2 billion and 252.7 workdays for the whole country. Not to even mention the effects on sleeplessness to our appetite. We crave sugar and carbs when we are tired, just to gain a rush then falling right back down again shortly after drinking a soda, eating candy, or a bag of chips. I recently had an extreme case of this... I woke up with a headache, popped a could of Advil, shortly after was extremely tired, the only way I could keep my eyes open was to eat and eat and eat. Later I realized that I popped two Advil PM, oops. 

It doesn't take much common sense to understand the repercussions that lack of sleep has on the human body. We have all felt the affects at one time or another. You've had a huge project in the making, a deadline is fast approaching, you have about zillion things on your to-do list, your mind won't stop going once you lay down to rest. And after a few nights of restlessness, you get a cold, your back pain starts to creep back again, you can't remember the details of your presentation even though you know that you know it. Why is lack of sleep important to know as a physical therapist? Because lack of sleep affects pain perception, healing, learning/memory, cardiovascular function, and modulating fear/anxiety. Sleep and pain may also be one those what came first, the chicken or the egg type of situations. A 2015 study that surveyed 73 physical therapists found that 93% of physical therapists agreed that poor sleep impacts pain and outcomes, however most (75%) did not receive education on sleep in during entry-level PT education and therefore do not have an adequate outcome to assess sleep.³

True, I did not receive education in school on how to assess sleep other than asking, "how are you sleeping?” followed by gaining a visual on the position of how one sleeps in order to give advice for better positioning. When I ask my patient's with pain, whether it be shoulder, hip, back, etc., how they are sleeping, it's generally poor. My follow up question before asking about their position is to ask how their sleep was prior to the pain/injury, in which often times it was still poor. Alright, so two quick questions that now give me some insight that this person has something else going on rather than just purely positioning. Perhaps it was the physiological effects that occur from sleeplessness (decreased pain modulation, healing, memory/learning, cardiovascular function) that is the primary issue. It is easy to feel tongue tied after that since we are indeed physical therapists, not psychologists. And physical therapists are not trained in how to ask the right questions. We are educated in how to rate pain (pain only subjective by the way), location, depth, 24-hour timeline, etc., but not necessarily the cognitive aspects of pain.

I was only able to find one study that assessed the extent of pain education that was provided to DPT students. The study surveyed healthcare educators, and 61% believed that their students received adequate education in pain management.⁴  That means 39% of students did not receive education on pain management. Obviously this is an area of improvement. I can't speak for all graduate level physical therapy programs, but the extent of pain education that I was provided was very limited. I remember watching a five-minute video in one class about the physiological/psychological effects of pain, and that's about it. After I graduated, there was a poll that was sent out to the students on whether or not they believed they gained enough knowledge on pain education, however I never heard the results of that poll. 

Sure, we can't do it all and at times it would be very appropriate to refer a patient to a psychologist. However, assessing sleep is within our scope of practice. Studies have demonstrated time and time again that daily, moderate exercise improves sleep quality.⁵  We can educate patients on how to conserve energy throughout the day in order to use that energy for exercise, family time, and social activities, thus improving one's quality of life. We can teach patients about proper sleep hygiene (please see my previous post Sleep Less = Achieve More? from August 25, 2015 for my sleep hygiene tips). We can teach pain education/modulation, giving patients ways that they can gain some degree of control over their pain.

When can we fit in all this information during our 30 minutes with a patient? At any point. Be creative. As physical therapists, we have to take responsibility to talk with our patients. I am lucky enough to be able to spend 60 minutes with my patients, others get 30 or 40 minutes. This is still such a huge chunk of time compared to many physicians who get maybe five minutes with an individual due to their huge patient load. Take the time at any point of therapy to ask. Ask open-ended questions, "so how is everything going", or more specific questions "do you feel like you are a contributing member to your work team?". Train supporting staff in how to listen/look for cues such as “I don’t feel like I have any control”, “I’m afraid this isn’t going to work, again”. Educate patients on the positive effects of taking 20 minutes during their lunch break to relax/recharge. Give them the confidence to put their wellbeing first, before their intense work pressures since we know that even with intermittent "mind breaks", they will still get the same if not more work done.

I highly encourage any therapists working with chronic pain and sleep deprived patients to purchase Adriaan Louw's book Why Do I Hurt? A Patient Book About the Neuroscience of Pain. This short self- help book is 52 pages and is written for patients. If you have trouble talking about the psychological and physiological effects of pain (like I do, hence I purchased the book), then you can lend this book to patients. It has great pictures and metaphors to help one's understanding of how pain affects the brain.

Each person is an individual; therefore we must not have one cookie cutter way to treat. If they don't like to read, don't give them the book. If they are on their computer all day, send them a couple of You Tube videos about sleep or pain education. If they are having difficulty taking short breaks throughout the day to just move, sit next to them while they put an alarm on their phone that goes off every 30 minutes to stretch. If they aren't ready to make lifestyle changes, then keep educating them. Give them the confidence that they can be active in controlling of their health.

Remember, the word doctor in Latin means 'to teach'.

References:

1. Milner CE, Cote KA. Benefits of napping in healthy adults: impact of nap length, time of day, age, and experience with napping. J Sleep Research. 2009;18(2):272-281.

2. Kessler RC, Berglund PA, Coulouvrat C, Hajak G, Roth T, Shahly V, Shillington AC, Stephenson JJ, Walsh JK. Insomnia and the performance of US workers: results from the America Insomnia Survey. SLEEP. 2011;34(9):1161-1171.

3. Siengsukon CF, Al-Dughmi M, Sharma NK. A survey of physical therapists' perception and attitude about sleep. J Allied Health. 2015;44(1):41-50.

4. Hoeger Bement MK, Sluka KA. The current state of physical therapy pain curricula in the United States: a faculty survey. J Pain. 2015;16(2):144-52.

5. Tang NKY, Sanborn AN. Better quality sleep promotes daytime physical activity in patients with chronic pain? a multilevel analysis of the within-person relationship. PLoS ONE. 2014. 9(3):e92158.