Treatment Table Podcast

Why You're Always Tired: The Hidden Link Between Sleep, Pain & Recovery

• Mathew Ah Chow • Season 1 • Episode 20

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0:00 | 48:03

Sleep is one of the most important pillars of health, yet it's often the most neglected.

In this special bonus episode of The Treatment Table, Mathew is joined by sleep physiotherapist Peter Allen from Melbourne Brain and Spine Group and SD Labs, alongside co-host and Women's Health Physiotherapist Dimi Tanyous, to explore the powerful connection between sleep, pain, recovery and long-term health.

If you wake up feeling stiff, sore, exhausted, struggle with chronic pain, or feel like you're doing everything right but still not recovering, this episode is for you.

We discuss:

• Why poor sleep can increase your risk of developing chronic pain
• The surprising relationship between sleep, inflammation and recovery
• Common sleep disorders, including insomnia and sleep apnoea
• Why waking up tired isn't normal
• How sleep quality impacts athletic performance and injury recovery
• The role of sleep posture, mattresses and sleep environment
• Practical strategies to improve your sleep starting tonight
• The "three-legged stool" of health: movement, nutrition and sleep

Whether you're an athlete looking to recover better, someone living with persistent pain, or simply wanting more energy and better health, this episode will change the way you think about sleep.

Resources & Links

Learn more about SD Labs:
https://sdlabs.com.au

Follow SD Labs on Instagram:
https://www.instagram.com/sdlabsau

Learn more about Melbourne Brain & Spine Group:
https://melbournebrainandspine.com.au

As a listener of The Treatment Table Podcast, you'll receive 20% off your first appointment at Active Movement Studio.

Book online at:
https://activemovement.com.au

Use code: TREATMENTTABLE20

If you enjoyed this episode, please subscribe, leave a review, and share it with someone who could benefit from a better night's sleep.

🎧 Episode Resources & Links

See you next week on the Treatment Table!

SPEAKER_01

Poor sleep with and with chronic pain. And actually, poor sleep preempts pain development. Fear of falling asleep at random times, at times when you shouldn't be, if you're yawning lots, if you find when you wake up in the morning, you're unrefreshed. You should be waking up refreshed. You shouldn't feel like you're groggy, you're exhausted. There's probably not enough sleep quality in there. Imagine every hour you're having 30, 40, 50 episodes where you just stop reading. Imagine doing that in while awake. Imagine how exhausting that would be.

SPEAKER_00

So this week we're interrupting the mini consult series for a very special episode that we didn't get to fit in into season one. So if you've been following the podcast, you'll know that I often talk about the three-legged stool. So that's your movement in nutrition and your sleep. So we've spoken about how there's different types of movement, performance, pain, recovery, nutrition. But today we finally get to cover the third pillar that's ugly, probably one of the most neglected areas, your sleep. So whether you're struggling with pain, stress, low energy, burnout, poor recovery, or brain fog, sleep affects everything. So we know from research that poor sleep affects your immune system, your mental health, it increases your risk of cardiovascular disease, Alzheimer's, and even your risk of having a car accident. So in fact, studies have shown that being awake for 17 hours straight has a similar impairment to a blood alcohol level of 0.05%. So today we're breaking down how sleep affects your pain, your recovery, your performance. But most importantly, from today's episode, you're gonna walk away with simple and practical steps to improve your sleep. And that's gonna help build that foundation of a healthier and happier life. To help unpack all of this, we're very fortunate today to be joined by sleep physiotherapist Peter Allen from Melbourne Brain and Spine Group. Peter's helping change how chronic pain is treated by putting sleep at the center of the conversation. And alongside me is our co-host, Dimi Tanyas, our senior woman's health physio here at Active Movement Studio. So you remember her from our early episode on pelvic pain. But since season one, Dimi and I have both completed the sleep and pain course in Melbourne through SD Labs, which completely changed how we view sleep, recovery, and pain. So Peter, thank you so much for joining us. And Dimi, welcome back behind the mic. Thanks for having me.

SPEAKER_02

Thanks for having me back. It's exciting.

SPEAKER_00

So Peter, let's dive in. Most physios don't talk about sleep in the consults. It's not something that we get trained to do. What drew you to specializing in sleep?

SPEAKER_01

Um, it was just, I guess, very fortunate. So I um work with Professor Tony Goldschlager, and he's a neurosurgeon at Melbourne Brain and Spine Group. Um, I've worked in for the last five or six years. And roughly four years ago now, he knocked at my door and said, Peter, there's a lot of my patients who are describing sleep disturbance. And you as a physiotherapist, I'm sending lots of patients your way for conservative management. And, you know, they're getting great results, but I'm still seeing that a lot of people are having sleep issues. Um, what are you as a physio doing to help people with sleep issues? And it immediately got me kind of stumped because I thought, you know what, when someone comes in, I do ask them about their 24-hour pattern of pain. I'll ask them how do they sleep? And a lot of the time they'll say, not so well, or I struggle to sleep, or I wake up sore. And that would be probably the end of what I say. I don't really talk much more because I'm out of my comfort zone. I don't know how to talk to patients much about it. I might say the token things like, do you go to bed on time? Do you wake up on time? Do you cut down on caffeine and alcohol? But actually having any meaningful, tangible advice and interventions for patients, I didn't really have much to go with. And that's really reflected in physiotherapy training as a whole. Like I think when you look at certain kind of um documents, if you look at the there's a big document that's produced in 2022 that talks about treating back pain, chronic back pain, which is incredibly common. Um, as we all know, as physios, you know, 80% of people will have some form of back pain throughout their life. Most people will recover, but unfortunately, some people go on to have chronic pain. And in Australia, um, you know, people over four million people have chronic pain. So, really, it was that it was a massive issue. We weren't having any actual meaningful outcomes for it. And we thought, well, firstly, myself and Tony, we actually spent about six months looking at the evidence and research. So Tony's a uh a researcher, he he specializes in stem cells um and in disc regeneration. Um, but we started to look at what is evidence out there regarding sleep and pain in particular, because just as you alluded to in your intro, there's a lot of evidence around sleep and um kind of cardiac disease and stroke risk and dementia. Um, but in terms of pain, it is well documented, but it's not well known. So, with regards to sleep and pain, there is some very strong evidence that shows that poor sleep goes hand in hand with chronic pain. Um, and actually, poor sleep is often preempts pain development. And for example, if you have an acute pain episode and you have in tandem with that poor sleep, you are much more likely to develop chronic pain or central sensitization, as we call it. Um, so we started to look into the evidence, we saw how strong and how big an issue it is, and we then saw that physios weren't doing anything about it. And that was my point. Basically, the document that physios deal with regards to back pain, there's literally 66 pages. And if you search for sleep within there, there's one word that says promote healthy sleep habits. So that's the only advice we get. And the doctors don't get any other meaningful advice. Um, and pretty much patients are kind of fumbling in the dark to try and find out what I can do to improve my sleep. My physio can't help me, my doctor isn't necessarily got time to help me. Um, maybe I can see a sleep physician. But again, even the sleep physicians, they're so snowed under with sleeplessness and uh the other byproducts of poor sleep that they want to try and address that pain isn't number one on their radar. So we started to think what could we actually do to provide an intervention to help those people who have sleep issues? Um, and once we knew that the evidence was there, we then saw that um one thing we could consider would be someone's posture in bed. It's a very simple idea, but what are people actually sleeping on? So typical bed, um, typically after seven to ten years, we're expecting it to start losing for it to lose its um properties for its support. Um and you know, a lot of people are dissatisfied with their beds, but the generic way of buying a bed is you go to a bed store, you feel it, you feel for mostly firmness. Does this feel good? And you give it a go. Um, but we wanted to see was there any way in which you could actually have a better uh choice out there and do do something where your physiotherapist was maybe involved in the actual uh decision. Because prior to all this, um, if a physic if a patient came to ask me about a bed, I would always be a bit worried. I would say, it's a big purchase. You have certain dimensions, you're a certain size, you sleep in certain positions, you have other issues going on, you have a partner in bed with you. I don't really want to give you the advice on that because you could be making something uh big expensive purchase that I'm not really comfortable with giving you an advice on. So we said, why couldn't a physio be involved in the actual um identification of um sleep issues, look at musculatal complaints, what position someone sleeps in, and actually fit someone with the bed. So it all started with that. And I guess where SD Labs comes into it is one of the actual former registrars of Tony, he was a doctor, a guy called Pratique Mando. Um, amongst other things, he left being a GP to actually become a part owner of Sleeping Dock, who are a big company in Melbourne. Um, and what he said was when we approached him, sure, we'll we'll um support you guys in considering a bed that could be prescribed for people with back pain. And that's what we did. We spent a year research and developing a bed with the evidence that's out there to create something that can actually help people with pain.

SPEAKER_00

Yeah, so I guess what's similar in my experience as well, it's like I'd ask the questions, right? And it'd be like, okay, you know, how are you sleeping? What time you go to bed, make sure you know you're not late on your phone before bed, but that'd be it, right? There's no tool, there's no intervention. Um, it'd be a conversation, and that would be it. Yeah. Um, going back to my previous working career as a registered nurse, we would just hand out sleeping pills. And that was that was the intervention for sleep. And if someone complained about not being able to sleep, you'd get the doctor to write a prescription for a sleeping pill. Um, but we know now that sleep is such an important part of our health, but I still feel like most people are aware of that, but they don't know what to do. They don't know, like we spend one third of our lives sleeping, but most people kind of just think of it as something that you just go to bed, close your eyes, and that should be it. Like, and then they get frustrated where that doesn't work, right? And you're like, hold on, why can't I just sleep? But you know, there's all these other things that compound into that, which we'll cover, we'll cover soon.

SPEAKER_01

Yeah, well, it's it's such a restorative time. And and I think we you lose that restorative nature when you take medications, when you take opioids because you've got chronic pain and you just want to get to sleep. You take alcohol because you just think I just need to sleep tonight, but it ruins your sleep architecture. You uh you take sleeping pills, which you know, in the short term, yes, okay, a week or two, maybe max, anything beyond that, you're becoming uh you're affecting your sleep architecture, you're becoming reliant on them.

SPEAKER_00

Why do you think? I mean, we particularly as physios, but I think general as well in society, we talk about exercise a lot. What's the best exercise? How much should you be exercising? What weight should be lifting, the intensity, HIIT training. And then we talk about nutrition, there's different diets. Yeah. How can we not talk about sleep? We're just not educated on it.

SPEAKER_01

Like, I think we all will innately be trying to search for advice that we can provide to our patients on sleep. I think, you know, you have Matt Walker podcasts, you've got Huberman, you've got Peter Atia, you've got all these people talking about the importance of it. And we all know for recovery, it's extremely important. But when you think about actually what's happening when we sleep, um, what's the prevalence of sleep disorders? Like how big an impact is a sleep disorder having on someone's uh pain and recovery, how big an impact is the position they're sleeping in and the posture they're in having on their recovery. I don't think we're really well versed in understanding the massive impact it can have. So I don't think we put enough value on it because we go to our really comfortable space, which we're very expert at, which is exercise and diet, and getting people moving and the biopsychosocial model and understanding all these components of just educating patients. But we're outside our comfort zone when it comes to sleep. And when patients then actually present with issues that need help for, we don't have interventions. We can't say, I want you to go and use CPAP because it's outside of a scope of practice at the moment.

SPEAKER_00

So, Dimmy, I'd love to get your opinion, your thoughts. Since doing the sleep course with Peter, what's changed the most in the way that you view sleep and also I guess with your clients as well?

SPEAKER_02

I think uh the pain course was definitely a big wake-up call. Excuse the pun on that one. Um, a lot of it I could actually apply to myself in terms of you mentioned there about sleep architecture and what sleep looks like. Um, what I got out of that course was, you know, we used to think a lot about the length, like the biggest thing that I guess we know about is, oh, you should have X number of hours per sleep. Adults should have this much, and that's that's good. But it's not just the length of time that you're sleeping, it's also the quality of that sleep. Um, and I think in that course, what we went through was, you know, the levels of sleep and REM sleep and the deep sleep and the zones and and what happens in those different zones to actually get restorative sleep or to get healing or regeneration or, you know, um reduction, inflammation, all those wonderful things that happen at sleep. So that's definitely changed the way I look at sleep. And now, you know, when patients come in and talk about their sleep, I'm thinking a lot more about what's the framework around their sleep, you know, what their sleep routines are. Um, because I'm also implementing more of that in my day-to-day. So I think I've definitely taken a personal approach into wanting to improve the sleep and understanding what's happening when I'm sleeping well, when I'm not sleeping well, and definitely applying that to patients. Um, you know, obviously there's a bit more to go there. Like we need, you know, a bit more supporting terms of they might need different times of types of treatment or assistance and, you know, mattresses, things like that. Um, but even just being aware that that is really important and not to ignore that a bad night's sleep is just a bad night's sleep, that there's something around that. And that could be something hindering your next day and hindering how you feel in the morning and how you know you perform the next day. Um, yeah, so I'm definitely putting a lot more emphasis on the importance of sleep rather than just making sure I get to bed on time or people get a number of hours. I'd say that's probably the biggest way I've changed my viewpoint on it.

SPEAKER_00

One of the questions that we got taught to ask was like, How easy is it for you to nod off during the day? And I was like, that's me all the time.

SPEAKER_02

Yeah, in the course, yeah.

SPEAKER_00

And I'm like, like, if I'm in the car, I'm out. Yeah. So I'm like, is that a sleep problem or is that a not enough sleep? Is it the quality of sleep? A lot of questions. Yeah.

SPEAKER_01

Well, did you do the effort sleepiness score? Did you check? Yes. Yes. So yeah. Like, you know, that's your body telling you, like, shut your brain down. I'm exhausted. You need to catch sleep whenever you can because you haven't gotten the sleep quality overnight. If you're sitting having a meal and you're not off, if you're sitting relaxing after lunch and you're not off, like sometimes, yes, there's tiredness. There's we all have busy lives, you have kids. At the end of the day, we're exhausted, we fall asleep on the couch. That's okay. Like, that's normal. We're all tired. But if you're falling asleep at random times, at times when you shouldn't be, if you're yawning lots, if you find when you wake up in the morning you're unrefreshed, you should be waking up refreshed. You shouldn't feel like you're groggy, that you're exhausted. There's probably not enough sleep quality in there. That could be sleep apnea, that could be it's insomnia, and it's maybe that you're struggling to get to sleep. You've woken up during the night. So many people with chronic pain have sleep maintenance insomnia. So they struggle to stay asleep. They have their first or second sleep cycle. We have five or six during the night. They have their first or second, and then all of a sudden they're awake, they're alert. They've basically, there's their nervous system is in this fight or flight mode. Their temperatures increase, their blood pressures increase, their heart rates increased, and they struggle to then relax. And they'll say, Oh, you know, I'm just a stressor. I just think of things. But realistically, that's not normal. You shouldn't be able, you should like people to say, Oh, my mind is busy, but that's more likely a physiological issue going on within you, that you're actually in that fight or flight mode, or that your brain is unable to disengage because you are tired, but you can't sleep. So, yeah, it's a massive issue. Something like uh sleep apnea, for example, um, it's it's highly prevalent in the community, like up to about 10 to 20% of Australians will have sleep apnea. Only about 5% or 6% know they have it, 80% is undiagnosed. So sleep apnea is incredibly common, especially in the chronic pain population as well, and in athletes, actually. So in athletes, it's actually more common because of their musculature or because of their uh body types. Um, but it's an incredibly common, undiagnosed issue. And imagine, like I always think of people with sleep apnea. Imagine every hour you're having 30, 40, 50 episodes where you just stop reading. Imagine doing that in while awake. Imagine how exhausting that would be. Imagine how your body is going into this fight or flight response every single time, and that your inflammation is just going through the roof. And no wonder you wake up feeling hungover. You feel like uncomfortable, sore, you're sensitive. Like we've all had those episodes where we've drank too much alcohol and we've all snored the night away, and then we've woken up, yeah, we've a hangover, but we're also just titchy and sore and uncomfortable. So, like, if something like sleep apnea can be addressed, and it's such an easy thing to identify, you basically score anything like five out of ten on a score, age, gender, next circumference. Uh, do you snore? Do you wake refreshed? Like easy stuff. And then when you come to insomnia, insomnia is incredibly common as well. So people with chronic pain, again, insomnia is highly prevalent, especially the they can often get to sleep, exhausted, pass out at the end of the night because you're so exhausted, but then you get woken and you just can't get back to sleep, and that's sleep maintenance insomnia. So it's just incredibly common, and CBTI is incredibly effective for it. So that's uh cognitive behavioral therapy for insomnia. 80% or so of people will have a positive outcome with CBTI. It's the gold standard for treating insomnia. So instead of giving the patient those medications in the hospital, I guess in the acute setting in the hospital, it's tricky. But if you could get a patient educated in the area of CBTI, which is what we're actually doing now at SD Labs, we're actually getting our physiotherapists, which you guys might eventually do some uh extra training on, in CBTI and actually being able to run four to eight sessions with a patient, tell them about their sleep, get them to understand it, and actually identify their issues with their sleep and see meaningful changes. Um, yeah.

SPEAKER_00

Yeah. So is is that insomnia the problem of just getting to sleep, or is it the problem of also then waking up and then not getting the sleep?

SPEAKER_01

Yeah, so it's both. So you have sleep onset insomnia. So everyone will have periods in their life where they struggle to get to sleep. It's normal. So you can get acute insomnia, which is very common. But actual clinical insomnia of sleep onset is you struggle to get to sleep, it takes more than 30 minutes, and we don't encourage anyone to clock watch, but you can kind of get a sense of it's taking your time. But three nights a week for three months in a row. So if you've got that in the absence of other um maybe medical conditions that could be affecting you, then you have clinical insomnia. And it's a very common thing, unfortunately, and it is tricky to treat with pharmacological interventions and other interventions, but CBTI, as I say, can be incredibly effective. And people with insomnia are much more likely to develop pain as well. So if you have chronic pain already and you have insomnia, your pain is gonna be incredibly sensitized, your pain threshold is reduced. But if you don't have pain and you have insomnia, the likelihood is much greater, double that you will actually have back pain in the future or other forms of pain. So, us as physios, just identifying sleep issues early on. Someone comes in to you, if they have a sprained ankle, like just talk to them. Do you sleep well? How do you sleep? That's gonna improve your acute recovery, but also reduce your risk of chronic issues. Another really good example is something like frozen shoulder. You know it's going to be something that's gonna take years to probably resolve. But if you can get them sleeping better, think about the restorative and the recovery components that'll happen overnight and the reduced risk of um chronic pain and that becoming a very chronic long-term issue. So, one of the first things I'll always do with any patient really is you get a good understanding of their sleep, tell them that they need to be improving their sleep, and just give them a very bite-sized, easy to understand way of if you don't improve your sleep, you you are going to be causing yourself maybe risk of future issues in terms of chronic pain, or your current recovery may not go as well as you'd like.

SPEAKER_00

What's the difference between with those clients that have good sleep and the ones that don't have good sleep? So the poor quality sleep. What is actually happening in the sleep that leads them to increase of all those risks that we've spoken about?

SPEAKER_01

Yeah, yeah, good question. So with something like, let's say, firstly, sleep apnea. So there's look, there's over 80 or so sleep disorders, but the most common are sleep apnea, insomnia. So you have sleep onset insomnia and sleep maintenance insomnia. So wake up, can't get back to sleep, and then you have restless leg syndrome. So they're the three most common. And um, each of them will, I suppose, have their own way in which they're affecting your sleep, but they're all impacting sleep architecture. So your ability of your body to go through stages of sleep and have the restorative effect of each of those stages. So something like sleep apnea, we're stopping breathing. So our upper airway is collapsing, we're snoring, we're having episodes where we stop breathing, and we're basically depriving your body of oxygen. So you go into what's called a hypoxic state. So you're losing oxygen. And when that happens, your basic nervous system goes into this state of fight or flight and it starts to say, um, there is a threat, you're you're not breathing. Send in inflammation because what that does is it's there to actually promote healing and restorative. So if you sprain your ankle, inflammation occurs as a healing effect. But if it's happening overnight repetitively over and over again, basically what happens is your nosoceptors, which is your ability to actually feel pain and they pain signal pain, they become constantly bombarded with inflammatory signals. They're starting to get pain. Um, you start to get heightened pain sensitivity. The more and more it happens every single night, the more your body is in this primed state for pain. And everything it does is going to be painful. We all know it. Like you wake up after a night of poor sleep and you are more sensitive. Or if you have a flu, or if you have a cold, your joints are sore, your back is sore. It's all because your body is storing this inflammation, not really resolving it. So But with that, we're we're with sleep apnea, just like it's basically doing that. With insomnia, we're struggling to get to sleep, we're struggling to stay asleep. So a big thing is we're losing out on many stages of sleep. So as I say, you should have four to five typical sleep cycles. That includes stage one, stage two, three, and rem. Um, with the stage three and rem in particular, we're getting that deep restorative sleep tissue repair. Um, you're you're starting to see your blood pressure drop, you're starting to see your heart rate slow down, your system goes from the fight or flight to the rest and digest. Um, but if you're not giving yourself the opportunity to go through those stages, you're not achieving all those healthy outcomes that come from going through those stages. And that can be a big challenge for those with chronic pain. So they will often lose out on something like REM sleep, which is towards the later part of the night, we get more REM sleep. So about 25% of your night is REM sleep, but it starts with small bouts in the first half of the night and then it becomes longer in the second half. So if you've got pain or if you've got sleep disturbance and you're not getting good quality sleep, one of the big benefits that we're now looking into regarding REM is muscle atonia. So the idea that you're asleep, you're in REM, your muscle completely disengages. So throughout the day, think that your muscles are working hard, they're doing their job, you're doing exercise, is great. They're doing what they should do. But a really great opportunity for them overnight is you go into total muscular silence in stage three, which is where your muscle activity really settles down. But then in stage uh REM, you're going into complete silence. You're going to get no activity because you don't want to act out your dreams. You're basically paralyzed. If you're not getting REM sleep, if you're not going into those stages, you're not getting the relaxation, hence, you're not getting the washing out, the flushing out of inflammation that occurs in those muscles during that stage. And you're basically waking up with a muscle that has been working that a little bit harder, it's not gotten the recuperation, and then it just repeats the cycle the next day and the next day, and it's just this constant cycle. So promoting um longer sleep, more sleep stages with insomnia certainly allows the body to go through those stages better.

SPEAKER_02

That's really interesting. And it brings me to a lot of, I guess, patients that I can think, gosh, I can list you so many of them that are probably fitting what you're saying is not getting that deep restorative sleep and feeling those effects of the um the you know, not getting rid of that inflammation. Um how do you think sleep position then comes into play? Um, so I have a patient at the moment who's in her mid to late 30s. She's got a four-year-old daughter. She's doing lots of carrying and lifting, but she's also working um full time. And she's been complaining of this shoulder pain, right? So shoulder, a little bit of hip as well, but it's really bugging her. And one of the biggest things she says is she wakes up and it feels the worst. It's the worst first thing in the morning, like as she's waking up. And, you know, that's starting to make me think, well, what's going on during her sleep? But again, well, you know, what do you do? You know, what's going on at during sleep in terms of positioning, you know, how does that affect the sleep cycles or the Yeah, yeah, yeah.

SPEAKER_01

Good question. That's what we're really working on with the bed that we've developed. So the issue with the standard bed is it's one single level of firmness, you don't put much of thought into it, you lay on it, and it might feel good initially. Those first few moments when you're awake, yeah, it feels nice, you're relaxed, you're comfortable. But think about when you go through the different stages, when you go into REM where you're atonic, no muscle uh control at all. So basically you're draped over the surface that's that you're lying upon. So if you're lying on your side and you've got a back that needs the support of a firmer bed, medium firm, firm, but your shoulder being a wider area that is basically got less tissue across it to actually protect the structures of the shoulder, the bursa, the tendons, they're going to be being put under extra load because you've got the broader shoulders and you've got the firmer surface. So people that are in bed and they're sidelining in particular on a sore shoulder, well, you're getting pressure. So you're getting pressure on certain structures of such as the bursa, such as the tendon. You're potentially also not getting the restorative effect of sleep because you're having restless sleep because you're sore. So you're moving around a bit because you're uncomfortable. So, what that means is you're probably not getting the muscle relaxation. So in the shoulder. So, what happens with relaxation? The capillaries, which are those tidy blood vessels within a muscle, they're they're when they're when they're engaged, when the muscles are tight, they're constricting, they're choking the muscles, they're stopping the muscle from be perfusing, basically blood flow moving through it and nutrients moving through it. If they're overly engaged, just like in the back, they're not getting that restorative effect. And therefore, you wake up in the morning, you're stiff, you're sore, you're not having that flushing out of inflammation. If you're on a slightly more, I guess, um, forgiving surface, such as a softer shoulder area, an area that's not compressing the actual tendon, the joint, the bursa, uh, and they're encouraging and promoting relaxation in the area of the muscle, you're going to get perfusion, you're going to get blood flow, you're going to get the washing out of inflammatory proteins and toxins that accumulate. And the person gets up and hopefully feels like their shoulder is not so stiff and not so sore. And it's the same for any other body part. Like if you can get the muscle in the most optimal, relaxed position, we encourage perfusion, we flush out inflammation. And that's why, you know, posture in the lower back is also so important. If the lower back is feeling any way threatened, like if you're in a sideline position, you're slightly sagging, seven-year-old bed, you think, oh, you know, it's a bed, it doesn't matter. Posture is not that big a deal. If it's in a position where the QLs, so the supportive paraspinal muscles or the deep down multifidus, which is that deep stabilizing muscle at the back, if they don't feel like they're safe enough to allow the spine to relax, because basically their job is I need to protect your spine. Think about when you're standing day-to-day life, they're working hard, they're doing their job, you have a pain event, they go into guarding, so the signals are there. The spinal cord could be at risk here, we've got to protect it. Then you go into lying, you should be completely switched off. They should have the opportunity to rest and recuperate. You lay in a poor position, you could even come into rem and you get what's called REM fragmentation, which is where you want to go into atonia, muscle relaxation, but your multifidus, your QL says, no, danger, can't relax because it's actually going to be in a poor position. My disc could be at fault here, my spinal cord could be at risk. So you get this broken sleep structure. So um that's just one component, like you know, of the shoulder, for example, pressure, muscle, but then you think about the disc as well. So if you're thinking about the disc in the lumbar spine, there's a process called disc imbibition, basically, where think of the disc like a sponge all day, it's getting squashed, it's getting axial load, it's getting pressure of gravity squatting down on it, and that's normal. We lose about 10 to 20 percent of disc height. Absolutely normal, no issue with that. You know, we all want to live active lives. But what should be happening overnight is that that re-inflates. So you basically wake up in the morning, you're taller, you're maybe one or two centimeters taller, um, and you're feeling like your back is actually not quite so stiff. But what's happening is you lie in a slightly suboptimal position, the muscles get tight, and they're actually restricting the opening up of the fascia joints. So the discs get a bit stiff. The disc isn't actually drawing in as much nutrients and water as it should do. It doesn't fill up and inflate, stays stiff. Um, and you wake up and you haven't received that therapeutic benefit of being asleep and being in a good position. And then something like disc desiccation, which is just that natural degenerative changes that occur in all of us in discs, but maybe it's more accelerated than those people because they're not getting that therapeutic basically plumping up of the disc every single night. So that was a long answer, but there's um yeah, a lot of reasons why that person, but that's a very common thing, like shoulder pain and sleep disturbance. Like it's it's I think 89%. I think I think it's really, really common. Um, and certain shoulder conditions are even more um affected by uh affected sleep. So as I say, frozen shoulder, for example, 100% of people with frozen shoulder will describe sleep disturbance. Um, it's probably the biggest challenge. And as I say, then that just puts them into that chronic pattern of sensitization and potentially then elongates the whole uh recovery process if if they do recover, and some people don't, they just have chronic shoulder issues then as a result. So yeah.

SPEAKER_02

Yeah, yeah. So I guess are you saying that simply changing their position can improve their sleep quality?

SPEAKER_01

Yeah, I look definitely in some ways. So um we'll all do it subconsciously. You will move your sleep position overnight because you your body is telling you this is a suboptimal position for me to be recovering. I'm lying in a position and my shoulders getting compressed, so I'm gonna roll onto my back. Or my back is a little bit twisted in this position, so I'm gonna kind of stack my knees and tough each other. So we all do it, and you know that people who are restless sleepers typically goes hand in hand with people who have some form of pain. So, what we're saying is that if you can actually create the optimal environment for that body to actually go into a restful state, you'll actually have less movement, which we've shown. We've done sleep studies, we've seen people that are wearing overnight devices that are moving less, they're getting to sleep quicker, potentially because their body is able to go into a relaxed state easier because it feels like, okay, I'm safe, I can relax here, I can switch off. The guarding doesn't have to take place. Um, and they're often then waking up with less stiffness. I think stiffness is a really good outcome to look at for most patients with regards to how is their recovery overnight going? If someone's saying, Look, I don't have much pain, but I wake up with six out of ten stiffness. I get out of bed first 20 minutes, I can barely start straight. Like it's really common. It's actually really common. You'll say to people, Do you struggle with sleep? Do you have pain? No, no, no, no. How do you get up in the morning? Oh, well, you know, I'm a bit stiff for the first 20, 30 minutes. Um, and that's a clear indication that the muscles have had to work harder than they should have. The recovery hasn't taken place as well as it could have. So, what we're saying is if we can prescribe a bed, if we can get the lumbar spine in the optimum position to promote complete relaxation, flushing out of inflammation, if we can deload the shoulder, if we can have the head in conjunction with that, the pillow. So we basically got a pillow that's going to be fitted with the mattress. So you basically have the head in a neutral position. What we were trying to achieve is not perfect alignment, because perfect alignment is such a silly thing idea because everyone has different postures and different positions. And if you have a scoliosis, you will have a natural curve, you will have a little bit of a different posture, and that perfectly straight line through the lumbar and thoracic isn't achievable. But if you can match what your body is is used to. So in standing, if you've got a excessive rounding of your thoracic, so you sleep on your back and you're really hunched over in sleep. That's the position that your skeletal system has has now adapted. That's what we want to try and promote. Because if we don't, your body's gonna say, This isn't the position that I'm comfortable in, and it's gonna guard and it's gonna get stiff and get sore. Um, so yeah, I think that was a long answer.

SPEAKER_00

Yeah, there's a lot to it, isn't it? And I think coming back to something you said that really resonated, and and we've touched a lot on this in some of the podcasts, is getting your body to feel like it's not under threat is really, really important. And if you can create an environment that's comfortable and not threatening, and it it can then actually relax and like you said, get those muscles to switch off, you're gonna get that restorative sleep. So you're gonna move through those cycles of sleep a lot better, which is gonna give you the benefits of that sleep. But if you're not comfortable, you're not feeling supported, that's where you're gonna cause a lot of issues. Which also then made me think a lot, and what are we doing during the day that's potentially causing us to have poor sleep quality? What are the habits or activities? Um, like you mentioned a bit before, opioids, alcohol. Um what other things are causing us to interrupt our sleep or put us into a state where we're not getting into those deep sleep, we're not feeling relaxed.

SPEAKER_01

Yeah. So I think I guess these are kind of well thought out ideas that are well researched, and certainly the big things that people will always be mindful of is coffee. So caffeine has a half-life of six hours. Caffeine um will reduce your sleep drive. So it basically we all feel it. It wakes us up in the morning, and what it's doing is it's blocking what's called adenosine. So it's stopping that, um, which is basically sleep drive. By the end of the night, it works in conjunction with your circadian rhythm and helps you fall asleep.

SPEAKER_00

Is adenosine is the chemical in your body that makes you feel really tired, makes you feel like, okay.

SPEAKER_01

There's two main processes that help you go to sleep, which is one is called adenosine, and the other is circadian rhythm. So adenosine is it starts, the clock starts in the morning, you wake up, it starts to build. And what caffeine does is it blocks it. So it blocks it, you feel a little bit more alert. You get the two o'clock slump, you have in the caffeine, you go again, you're an athlete, you take your energy just before maybe a 7 p.m. match, and great, you feel better. But what that's doing is it's obviously impacting then your sleep quality because that sleep drive isn't quite so much there. What also means is you might fall asleep, but let's say the half-life of coffee is six hours, you've had four coffees and maybe 7 a.m., 10, 12, 20, that all adds up accumulatively. So at the end of the day, 2 a.m., you could still have the equivalent of let's say two coffees. It could just be like you've just had two coffees. And your body will go through maybe the initial sleep stages, but then be woke and struggle to sleep. So a big one is for everyone just uh cut your coffee off by 10, 11 a.m. I think that's a tricky one for some people, but it's a good one. Um, another is alcohol.

SPEAKER_00

Just have all my coffee.

SPEAKER_01

Yes.

SPEAKER_00

Yeah.

SPEAKER_01

Depends on if you have a mass, how many shots can I have? If you have an overdose of coffee, the half-life of that dose will be six hours. So uh it'll slowly just dwindle down, quarter life, 12 hours. So you'll still have a bit in your system. But um, caffeine is obviously in tea and energy drinks and lots of other things as well. So I think it was my wife who didn't realize she just bought decaf coffee uh tea bags every night. She was having tea and then didn't realize. Um, other things, uh alcohol. So alcohol is a sedative, it will often make us feel sleepy, which is, you know, for some people a good thing, but it massively impacts your sleep architecture. So you start to drop down, you don't go through the four natural stages of sleep. You drop straight down at the REM, and then you come shooting back up into light sleep. And anyone who's drank too much alcohol will always know that their sleep is, they often feel tired. The next day they're often um cranky, they're sore, they're eating more. Um eating more is another idea because we actually do uh when we don't sleep well, we do eat more. The I think up to some studies suggest up to 600 calories per day. So if you want to lose weight, you have to be sleeping well because otherwise it's just impossible. Your your your hormones will be different. You're your your leptin and your ghrelin. So your feeling of satiation and your feeling of um hunger will be heightened. Um what else in terms of exercise? So exercise first thing in the morning is often a good thing. It sets and it goes in line with your circadian rhythm, so it can really help your body to understand when is um morning time, when is night time. You can exercise later in the day, but they do say that up to two to three hours before bedtime you should be cutting off. Um, other things like blue light is another big one. Again, we'll all look at our phones, um, we'll all do all those sort of things, but what it's doing is it's suppressing melatonin secretion. So at nighttime, your body will naturally secrete melatonin and it will tell you to add that to get ready for sleep. Um, if you have blue light in your face, it will actually start to suppress the secretion of it. So ideally, you would be cutting down on blue light, which would be the filter on your phone, maybe. And there's actually also research that shows that how close that blue light is to your face also impacts it. So if you can't put down the phone, at least keep it away from your face, keep it down around your lap or somewhere. Um yeah, other like there's there's there's whole heaps of of ideas that people should be considering with sleep, but you also don't want to you also don't want to become anal about it and also cause yourself insomnia. You don't want to be thinking about the other way, yeah, sleep and and be so uh anal about it and think, oh, I've got to worry about my sleep now. Um if you don't have sleep issues, you know, it's fine. Like you can do all these things, the odd occasion you have alcohol, or you do try and cut down your caffeine because it doesn't impact your sleep architecture. But in general, if you can just um yeah, the one I missed actually, sorry, was uh morning light, which we kind of all um I think are aware of, but the idea that the body then again, the the eyes will take on light, they'll be able to realize that it is morning. Again, it's for your circadian rhythm. It's basically so that you're you're if you ever travel, for example, the big thing is to actually go and get a good amount of light into your system so that your circadian rhythm starts to think that it's daytime and it's nighttime.

SPEAKER_00

If our listeners could only change three things today to help their sleep and their sleep quality, what would you pick for those top three?

SPEAKER_01

Um Well, because I'm so invested in certain areas, I'll give maybe slightly skewed answers, but one would be understanding that sleep disorders have a massive impact on um your overall well-being. Um, something like snoring, like we'll all have potentially family members, parents. Uh I know my dad for 30 years was snoring the house down, and now I think this guy 100% had sleep apnea. And he never, I never like I'd love to have told him about it because the impact that's having on his quality of life. Um, so I think one is just don't like disregard things regarding sleep. So if your sleep is bad, do something about it because it has such a powerful impact on your well-being, um, pain, but also so many other facets of life, mental health. Um, so if you think that you have any signs of sleep issues, it's very easy to just get it assessed. And now the physios here can obviously advise and talk to you, but then you can also sleep, speak to doctors and sleep physicians about it. Um, you could do something like, as I say, a stop bang, which could be a questionnaire to check for sleep apnea, or the Epbert sleepiness score for am I excessively sleepy? Um, another, again, I'm going to lean into just the area that I'm focusing on is your sleep environment. Um, so that comes down to a number of things. So, in terms of at nighttime, keeping the room nice and cool. So, about 19 degrees is a good temperature to have in your room. You want darkness. If you need to use eye masks or earplugs, then you should. Um, the bedding that you're sleeping on, um, the actual mattress, the bed, the pillow, should be considered in terms of anything beyond seven to ten years, it's getting old, it's getting past its due date. Um, the research does suggest that in general a medium firm mattress is more superior to a firm mattress. So if you were to just buy a generic one, you might consider a medium as opposed to firm. Um, but if you are having stiffness, if you have chronic pain, um, if you're an athlete who wants to get that extra few percent out of your performance and recovery, um consider our system, the Z10 sleep system, because honestly, the results we're seeing now are incredible. The fact that you can trial a system for 12 weeks, you can be fitted by your physio who can understand your specific needs and who can track. That's the key. Like you go and you buy a bed, you spend thousands of dollars on it, you don't know if it's good or bad. But this way you can track, you can actually see am I seeing tangible improvements in my pain, in my recovery, my sleep quality. We will do sleep scores before, we'll do them after, we'll do pain scores, and you can get a really good sense as to whether or not you're seeing improvement. Um, so that would be a second one. And then thirdly, I think it's all of the stuff that I really talked about to begin with, which was really the basic sleep hygiene ideas. They the research really strongly supports them. Like they really are effective. If you cut down on caffeine, cut down on alcohol, get your morning light, do your daily exercise, um, reduce your blue light. Yeah, if you can do those basic ideas, then you can certainly set yourself up for a better night's sleep.

SPEAKER_00

Yeah, no, I love that. It's so much more involved, and there's so much more to sleep than just this thing that we just shut our eyes and we we go to bed and then hope for the best, right? So I think today's conversation is just the start of something, like you said, and to be able to become aware of your symptoms and understand that there's probably more to it than just being tired or fatigued or waking up stiff. And the more we can become aware and more of these conversations we start is gonna open up to improving so much more better life quality. Um, and we know that if we improve our sleep, it's gonna improve the longevity, right? Yeah. And it's such an important part. And if we can start to make those small little habit changes, the sleep quality, improve our sleep environment, you know, we might be doing all the exercise and might be doing all the eating right. But if we're missing out on that last component and you're doing all those bad things, you know, you're taking away from all the effort that you're doing. And it's like you're you're you're not getting the benefits of all the hard work you're doing. So this is something that, you know, a conversation I've really been wanting to have because a lot of this gets missed. And it's it's sad from my side when I see people trying their best to do their best, but they're missing such an integral part. And I really believe that if people can get the movement, can get the nutrition, and now get the sleep, all that makes such a good foundation that then everything starts to fall in place. 100%. Yeah. Awesome. Is there anywhere where our listeners can find some more information around sleep?

SPEAKER_01

Yeah, look, um firstly, we've your physiotherapists now, we have 60 clinics cross country being able to talk about sleep in a very meaningful way. So some of the stuff I've spoken about um is something we're trying to get into the physiotherapy community as a whole. You know, universities are asking us to speak now because sleep isn't something that's on their current curriculum and they want us to be able to involve, get involved with their students. But your physios now can be someone you can talk to, and certainly in this clinic, you both you guys. And hopefully more of your um physios and EPs can potentially go down the route of training as well. Um, then there's all the typical kind of avenues, such as just even speaking to your GP. You can get a fully Medicare rebatable sleep study if you simply have signs of sleep apnea and you also have sleepiness. So, you know, it's not that hard to make the first steps of just investigating these things. And the difficulty is it's this silent kind of killer, I suppose, because it can kill you, obviously, obviously prolonged poor sleep, but um you don't appreciate it because you're asleep, you're at time. But it's it's one that if you actually do put some effort into and actually do um investigate and treat, like people call it like the fog has been lifted, um, their lifestyle improves so much, their mental health improves so much. Like I would say that every major disease is as has like sleep affected with it. Um, and a big component of that is inflammation and inflammation in the body. And if you can actually use the body's natural way to restore itself, to heal itself through just improving itself and over sleep, you just got to give it the right uh tools and right environment to do so. Um, so yeah, I'd say just have the conversation with your physio, with your doctor. Um, if the doctor who is incredibly busy struggles to kind of go into a meaningful conversation with you around sleep and pain, I would certainly speak to the physio who's now expert in that area.

SPEAKER_00

Where can all this find out more information about SD Labs?

SPEAKER_01

Yeah, so uh SD Labs, SD laboratories. If you search either online, you'll find our website where you'll see uh a little bit more about what we're actually doing. We have been in recent um on the on the website, there's recent newspaper articles and uh client stories because uh I suppose at the end of the day, what we're really trying to see is meaningful changes in people's lives, and across the board we are seeing those. So you can learn about some of those on the website, um, our LinkedIn, uh, our socials in terms of Instagram, SD Labs. Um, and I would imagine the kids are using TikTok, which I don't use. Danny and our team is probably doing that. Um, so yeah, so there's heaps of ways in which you can learn more.

SPEAKER_00

Thank you so much, Pedo. That was awesome. There was a lot more questions that we didn't get through, but that's all we have time for today. So thank you so much for coming into Active Movement Studio, all the way from Melbourne. And thank you so much, Demi, for joining us back behind the mic on the treatment table. Hopefully, we can get you back on again. A lot more questions to ask and carry through. And I think more conversations around sleep is so important. I think this is just the start. And so thank you so much for bringing the conversation to light, and thank you so much for driving this as an important tool. I think um that, like I said, it's an area that hasn't been addressed enough and there's not enough that we can practically do. And so I think it's a great first step in terms of making, you know, like you said, better outcomes in terms of not just our clients' lives, but everyone around us. So thank you.

SPEAKER_01

Thanks for having me. Uh, I will be back up in the near future. I will be up to talk to uh your team members in clinic about this. So it'll be nice if any uh listeners want to actually attend in the night and actually have any further questions that you want. More than happy to spend some time with them. Amazing. Thank you.

SPEAKER_02

Thanks for having me back on. Thanks to see you again, Peter.

SPEAKER_01

Yes, I see you too.

SPEAKER_00

I can finally sleep better now. We've completed the three-legged stool. Yes. If you've enjoyed this episode, please subscribe, leave us a review, or share it with someone who probably needs a better night's sleep. And remember, as a listener of the Treatment Table podcast, you get 20% off your first appointment at Active Movement Studio. So you can head to our website, active movement.com.au, and use the code TREATMENTTABLE20 when booking. We'll see you next week back for another mini consult episode. So if you've got any questions, please make sure you can send us through your questions through Instagram or send me an email at treatmenttablepodcast at gmail.com. We'll see you next week on the treatment table.