by Corey Hazama, PT, DPT, OCS, CFMT, PRPC, WCS. Corey guests on this weeks blog from her office in Downtown Manhattan at Beyond Basics Physical Therapy. She will join Amy Stein as our Self Care Workshop Leaders at the Endometriosis Summit. Sleep can be crucial to combatting pelvic pain and for brain health. Corey writes:
In recent years, with the advancement of social media, Self-Care has taken on a life and meaning of its own. Self-Care is more than a face mask on a Friday night; it includes a variety of strategies that people undertake to establish and maintain their own physical and mental health. The World Health Organization defines Self-Care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider, based on their knowledge and the information available.” It encompasses many different categories, which includes hygiene, nutrition, lifestyle, environmental and socio-economic factors, and self-medication.
Now that we understand the bigger meaning of Self-Care, this brings us back to the topic of Sleep. Sleep is the ultimate Self-Care act. Poor sleep has been implicated in a number of negative health consequences. But as individuals, we can empower ourselves to take the responsibility to make changes to ensure a good night’s sleep. Self-Care is also not just something that the healthy do to stay healthy, but also something that is essential for those with chronic disease to be able to self-manage their condition and symptoms.
More and more evidence supports the importance of sleep and its effect on our well-being, physical health and ability to heal, cognition, and how much pain we feel. This makes sleep the ultimate Self-Care act because it is something we do every day and there are so many ways to alter to increase the likelihood that our quality of sleep is improved so that we can reap the benefits of a good night’s sleep.
Sleep is needed to sustain life. Studies show that poor sleep actually shaves years off of our lives. There are also a number of conditions that are affected by insomnia. A study of 1,869 cases of migraines showed that sleep protects against migraine attacks and that 29% of migraines were directly related to insomnia. Another study in 2016 found a relationship between insomnia and absences from work due to illness, demonstrating a connection between decreased sleep and decreased immune function. Numerous studies have shown that sleep disturbances are related to an increased prevalence of obesity, insulin resistance, type 2 diabetes, cardiovascular disease, and also to metabolic syndrome. Metabolic syndrome is a subtle systemic inflammation which can occur when there is increased stress, anxiety, depression, insomnia, as well as obesity and inactivity, resulting in a potential driver of chronic pain. Insomnia preceded 40% of psychiatric mood disorders and sets in at the same time as another 20% of mood disorders. Lack of sleep can affect athletic performance, whereas better sleep improves it. In addition, there is a negative impact on healing and recovery..
A 2019 study found that sleep deprivation boosts responses to pain in the areas of the brain that sense pain, and it suppresses activity in areas that modulate pain experiences. This means the brain perceives more pain coming from our nerves, and has less ability to dampen the response. A study in 2016 on 133 patients with knee arthritis compared those who slept well versus those who did not, and it found a high degree of certainty that decreased sleep, or fragmented sleep, strongly affected the pain and central nervous system relationship, what we know as central sensitization, or when the inputs into the central nervous system are amplified.
There are two types of sleep: REM (Rapid eye movement) and non-REM sleep. During the night, we cycle between these two types of sleep, completing on average four to six cycles. The type of sleep one gets is more important than the amount of sleep. You could sleep for eight hours, but if you are not entering REM sleep, the benefits will not be the same. There are a number of factors that determine our daily rhythm of being awake and sleeping, as well as other body functions, otherwise known as our circadian rhythm. Light stimulates this rhythm as well as hormones. It is generally recommended that we get about 6-10 hours of sleep, but it varies between individuals. Most adults need about 7-8 hours to feel fully rested.
The major factors that disrupt sleep are acute Stress (major life changes), physical illness (that causes pain) and psychological problems (depression/anxiety), but a number of specific habits or activities also can affect sleep.
-Going to bed and waking up at different times every day
-Taking naps during the daytime or in the evening
-Drinking caffeinated beverages after 3 PM
-Smoking nicotine, which is a stimulant
-Sleeping in a noisy bedroom
-Sleeping in a room that gets a lot of light (good luck New Yorkers!)
-Drinking alcohol in the evening may relax you at first, but alcohol does lead to disturbed sleep
-Having heated arguments with significant others or roommates before bed
-Using the bedroom for working or watching TV
-Sharing the bed with a snorer or restless partner.
The question to ask yourself is, which of these activities do you feel you have control over and you can change? There may not be much you can do, for example, if you have a snoring, kicking bed mate, besides urging them to seek medical help, getting ear plugs, or trying one of those mattresses that claim to minimize movement (anyone remember the wine glass and the bowling ball commercial?)
What helps sleep?
-Getting exercise every day
-Taking a warm bath 45 minutes before bedtime
-Drinking a caffeine-free herbal tea 30 minutes before bedtime
-Learning relaxation/tension release exercises like deep breathing or progressive muscle relaxation
-Unplug an hour before bed (including your phone!)
-Get up if you can’t fall asleep within 20 mins and return to bed when you are sleepy
-Set the alarm for the same time every morning
-Dim the lights before bed
-Try lavender aromas and self-massage for relaxation
-Unwind by doing something relaxing like reading a good book (no thrillers, people!)
-Write a journal to get all the things in your head that are running around and causing you more stress on paper and out of your brain
We can all also benefit from locating the stressors we can eliminate. If we are still having problems we can’t overcome on our own, it could be time to talk to a mental health professional.
In addition, if there is musculoskeletal pain that is prohibiting you from getting enough sleep or finding a comfortable position to sleep is a problem, a physical therapist is a good place to start. A physical therapist can work with you to decrease musculoskeletal pain and help with strategies to find improved posture and better alignment to decrease strain to your body, which will help to promote better sleep by allowing your body to relax and decreasing pain.
-What is Self-Care? -ISF isfglobal.org/what-is-SelflCare/ -Sleep Self Care University Health Services Tang Center S:/handouts/Clinical/Insomnia.doc 6/23/16 12:16PM
-Paul Ingraham, Pains Therapy Theory New Books Contact; Insomnia Until It Hurts: The role of sleep deprivation in chronic pain, especially muscle pain. http://www.painscience.com/articles/insomnia-unil-it-hurts.php
-10 Self Care Habits to Relieve Stress Before Bed-Awake & Mindful. Awake & Mindful (httyps://awakeandmindful.com/)
-Jo Nijs, et al. Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Physical Therapy, Volume 98, Issue 5, May 2018: 325-335.
-Barbara Rigel, et al. Poor Sleep and Impaired Self-Care: Towards a Comprehensive Model Linking Sleep, Cognition, and Heart Failure Outcomes. Eur J Cardiovasc Nurs. 2009 Dec; 8(5): 337-344.
-Patrick H. Finan, et al. The association of sleep and pain: An update and a path forward. J Pain. 2013 Dec; 14(12): 1539-1552.
Joining the Endometriosis Summit all the way from Oregon, Dr. Amanda Olson, PT DPT, PRPC is a specialist in all things pelvic floor and exercise. A long time faculty member for the APTA, she will share her expertise on running and endometriosis. Amanda also created, designs for and own Intimate Rose, a pelvic health products company for dilators, kegel exercise weights, pelvic wands, and pelvic health supplements. She writes:
As many people with endometriosis (endo) know all too well, exercise and physical activity are important in managing symptoms of pain, inflammation, as well as maintenance of bone, musculoskeletal, and cardiovascular health. On the other side of this coin is the fact that it can be difficult to get up and move in the fits of an endometriosis pain episode. “Motion is lotion” as they say, and gentle yoga, Pilates, and cardiovascular exercise can help reduce inflammation and decrease pain. Endorphins are released with exercise and these “happy” chemicals can also help with coping strategies for endometriosis symptoms. The amount and intensity of physical activity needed for optimal health varies for each person living with endo, however these tips can help provide an overall guide. Working with a physical therapist who specializes in pelvic health and who has education in endometriosis is also helpful in curating a program to fit your unique needs.
When considering an exercise routine, it is important to remember that endo adhesions can cause disruption in the orientation of the pelvic organs, and in the abdominal muscles themselves. Additionally, laparoscopic surgery and other abdominal and pelvic surgeries can result in scar tissue in the abdomen. Endo adhesions and scar tissue can result in the disruption of the normal length, tension, and tone of the abdominal muscles. Retraining the muscles and the pelvic floor how to properly contract in co-ordination is key to restoring stability to the body.
Providing stability to the body during exercise and functional movements of daily living is a matter of mechanics. If the trunk is thought of as a house of our organs, the diaphragm forms the ceiling, the pelvic floor forms the floor, and the abdominals and deep back muscles form the walls. When the abdominals are affected by endometriosis, the walls of our “organ house” become weaker, which provides less stability for the ceiling and floor. This alters our intra-abdominal pressure (IAP), and can affect the piston-like mechanics of the diaphragm and pelvic floor, which work together to create efficient breathing.
Furthermore, it is important to note that the abdominal muscles work in symphony with the pelvic floor muscles, diaphragm, and small muscles in the spine called the multifidi to stabilize the trunk, promote effective breathing, and maintain IAP. The diaphragm and pelvic floor work in a piston-like manner wherein as the diaphragm drops drawing breath into the lungs, the pelvic floor also drops. To expel air it is vital that the diaphragm returns to its resting point and the pelvic floor lifts back up. This requires that the muscles maintaining the walls of the trunk are strong and hold form. Thus, the abdominal and other core muscles are important in maintaining proper intra-abdominal pressure (IAP) for breathing, posture, and bracing the spine during functional movements as well as when you cough, sneeze, have a bowel movement.
Retraining the core muscles to contract in coordination with your breathing for optimal exercise requires some practice. One exercise to get you started is the pelvic brace exercise:
Pelvic Brace exercise: lie down on your back with knees bent and feet shoulder width apart. Inhale gently. Then exhale and contract the muscles of the core by imagining that you are shutting off the flow of urine while drawing your abdominals slightly inward. Your gluteal muscles should not be contracting, and your pelvis should remain perfectly still, not rocking or tilting. Initially, try to hold the contraction for 3-5 seconds. Rest for 5 seconds. Repeat 10 times, and do 2-3 sets.
Conversely, it is important to master the co-ordination of relaxing and expanding the pelvic floor, also referred to as a pelvic floor “drop”. To perform a pelvic floor drop:
Pelvic drop exercise: lie down on your back with knees bent and feet shoulder width apart. Inhale and feel the pelvic floor expand gently away from your sits bones. It might help to envision that the muscles around the urethra, vaginal opening, and rectum are a bubble gently expanding down and outward. Try to maintain the drop for a count of 3 (without holding your breath), then relax and allow the muscles to return to a resting position. Repeat this 10 times and perform 2-3 sets.
These basic exercises are cornerstone exercises which allow for flexibility, co-ordination, and control of core. These can implement throughout the day and added to a pre-existing exercise regime. A pelvic physical therapist can provide additional exercises, manual therapy, and modifications to help you find a routine that honors where you are in your stage of endo, to help you reach your goals.