The Physical Therapists at Northern Rehab regularly incorporate the discussion and evaluation of sleep habits as part of our physical therapy treatment plans. The role of physical therapists’ work in prevention and management of sleep impairments and promotion of healthy sleep behaviors. Below is an excellent and informative article from the American Physical Therapy Association (APTA). If you are having trouble sleeping, please contact us and speak with one of physical therapists to discuss your sleep habits and to learn strategies for proper sleep.
A Good Night’s Sleep: Physical Therapist’s Role in Patients’ Sleep Health
When Keith Poorbaugh, PT, ScD, was nearing the end of an initial evaluation with a patient, he was surprised when the man began to sob. The owner of Northern Edge Physical Therapy in Wasilla, Alaska, had only asked a basic question: How’s your sleep?
“He explained that his sleep was terrible,” recalls Poorbaugh. “His wife complained about his snoring, he felt restless, his pain always felt worse as he tried to settle into a comfortable position, and he felt that he would only find rest when he was dead. I couldn’t just walk him into the gym for some basic exercises and ignore the burden he was carrying.”
According to the U.S. Centers for Disease Control and Prevention, about 70 million Americans experience chronic sleep problems. Lack of sleep is associated with injuries, chronic diseases, mental illnesses, poor quality of life and well-being, increased health care costs, and lost work productivity, the CDC says. Sleep problems are major contributors to myriad conditions, including obesity and depression. In fact, the CDC considers sleep health so crucial that lack of it is considered a public health problem.
Poorbaugh’s experience with that distraught patient taught him how to begin discussing overall wellness — not just mobility issues — with his patients. Author of “Healing Power of You: A Guide to Wellness and Healing,” Poorbaugh writes about a “Wellness SAFE,” which covers four pillars of wellness: sleep, activity, fitness, and healthy eating.
“Most people think of sleep as a state of relaxation or escape to dream,” Poorbaugh says. “In reality,” he explains, “sleep offers more of a restorative function than simple relaxation. Sleep is relied upon by every human system for tissue repair and recovery of vital nutrition. Every health care provider should be involved in sleep health.” He adds, “Physical therapists are among the few health care providers who truly understand the value of wellness as the fundamental platform for healing pain or improving movement-related disorders.”
To enable his patients to understand the importance of proper sleep, Poorbaugh explains to them how it can affect movement, “Our movement system is constantly adapting and compensating for imbalances. If we want to heal a movement dysfunction, then we have to change something that affects all systems,” he says. “Wellness is the simplest route toward changing the health and function of any system. If we sleep well, act well, feel well, and eat well, then our movement system is best suited to get the most out of any intervention or treatment.”
Alignment With American Physical Therapy Association (APTA) Positions
In 2020, APTA’s House of Delegates adopted the position “The Role of the Physical Therapist and the American Physical Therapy Association in Sleep Health.” In part, it states:
Physical therapists are part of an interdisciplinary team of licensed health services providers in prevention and management of sleep impairments and promotion of healthy sleep behaviors. The physical therapist’s role includes using the best available evidence and standards of practice to:
- Screen for sleep dysfunction
- Identify impairments related to sleep dysfunction
- Implement and progress therapeutic interventions to address impairments that interfere with sleep
- Educate society, patients and clients, caregivers, and providers on healthy sleep behaviors and the relationship between sleep, pain, physical activity, function, health, and wellbeing
- Monitor and, if indicated, manage sleep quality and quantity in patients and clients to enhance physical therapy outcomes
- Refer to sleep medicine professionals as indicated
This House position aligns with many APTA positions and policies, says Hadiya Green Guerrero, PT, DPT, an APTA senior practice specialist. “This position is one of the branches further teased out of all the positions of APTA that support physical therapists’ roles on primary care teams, annual visits, and overall prevention, health promotion, and wellness, in addition to traditionally thought-of areas of physical therapy such as rehabilitation, habilitation, and hospice and palliative care,” Guerrero explains.
“Sleep is a part of human behavior and movement and is essential to life. There are aspects of it that PTs are experts in, such as positioning for prevention and rehabilitative reasons. This position makes it explicit that PTs are involved in and should be mindful and helpful in the area of sleep, which lends naturally to working with, learning from, and sharing our knowledge with sleep professionals.”
The 2020 House position is a reflection of — not the catalyst to begin — efforts toward recognizing and promoting the profession’s role in addressing sleep health. (For example, a 2018 article in APTA Magazine’s predecessor PT Magazine titled “Promoting Sleep: Not a Leap” addressed the issue.) However, to put the position’s words into action, next steps in the ongoing initiative are to develop a project plan through the APTA Health Promotion and Wellness Council. The council was established in 2017 as an association community for members who want to collaborate on incorporating prevention, health promotion, and wellness into physical therapist practice.
Patrick Berner, PT, DPT, RDN, is chair of the council, owner of Fuel Physio, LLC, and adjunct faculty at Baylor University, South College, and DeSales University. He says “Sleep always has been one of our main focuses when it comes to consideration of health behaviors — joining physical activity, nutrition, and stress management. This includes the screening of sleep health, providing education and behavioral intervention when appropriate, and referring to another provider when necessary. As far as a plan, we are working on standardizing the inclusion of health behaviors and social determinants of health within patient care. The difficult part of that task is that every person’s community and individual needs are different.”
Guerrero, the APTA staff liaison to the council, says, “The work has begun and includes identifying member subject matter experts on sleep and developing resources.”
Helping Patients Sleep
Poorbaugh’s patient reacted emotionally from lack of sleep. Kara Schuft, PT, DPT, also has seen poor sleep affect patients cognitively. “Sometimes, I’m trying to teach a movement pattern and notice that patients cannot follow or that recall is really poor,” says Schuft, co-owner of Whole Body Health Physical Therapy in Portland, Oregon.
The paper “Sleep Health Promotion: Practical Information for Physical Therapists,” published in 2017 in PTJ — Physical Therapy & Rehabilitation Journal, identifies this and other bodily functions that require good sleep health: “Sleep is critical for immune function, tissue healing, pain modulation, cardiovascular health, cognitive function, and learning and memory.” It also explains what can happen when patients don’t get enough sleep: “Without adequate sleep, people can experience increased pain perception, loss of function and reduced quality of life, depression, increased anxiety, attention deficits, information processing disruption, impaired memory, and reduced ability to learn new motor skills, and are at an increased risk for accidents, injuries, and fall.”
Although some PTs do have expertise in sleep health, all PTs can learn how to evaluate and advise their patients. “A physical therapist with an expertise in sleep health,” explains Katie Siengsukon, PT, PhD, “will screen the individual for possible sleep issues, consider how the condition that brought the individual to physical therapy services might be affecting their sleep, provide sleep health promotion education tailored to the individual, and refer the individual to a physician for further assessment if a sleep disorder is suspected.”
That’s significant, she says, because “a large number of sleep disorders go undiagnosed and thus untreated, so we should be part of the team of health care providers who screens for sleep disorders.” Siengsukon is associate professor in the Department of Physical Therapy and Rehabilitation Science and director of the Sleep, Health, & Wellness Lab at the University of Kansas Medical Center. She also was the lead author of the PTJ paper.
“Sleep promotion education encompasses recommendations to entrain your circadian rhythm (such as waking up around the same time every morning and exposing yourself to light in the morning and during the day), increasing your sleep drive (getting out of bed if you are not able to fall asleep or back to sleep, avoiding naps, exercising, and being physically active), and decreasing presleep arousal (using a relaxing bedtime routine and practicing relaxation techniques). Other behavioral and environmental changes to promote sleep quality — generally referred to as “sleep hygiene” — include keeping a bedroom dark, quiet, and comfortable; avoiding alcohol and large or spicy meals before bed; and not viewing computer screens an hour or two before bedtime, explains Siengsukon.
If PTs and PTAs believe patients need more help than they alone can provide, it may be time to involve other health care providers. Siengsukon suggests referring the patient to a physician who is board-certified in sleep medicine. If this isn’t an option, refer the patient to their primary care physician. Or, to a psychologist or psychiatrist: “Sometimes an underlying issue is contributing to or perpetuating their sleep issues that needs to be addressed, like anxiety, depression, or a recent or past trauma,” says Siengsukon.
Will this interdisciplinary involvement lead to more opportunities for PTs and PTAs? Possibly.
Siengsukon says that while PTs and PTAs already work with many health care providers who specialize or have training in sleep health issues, “Physical therapy is expanding into prevention, health promotion, and wellness. Sleep health is an essential component of those areas. PTs and PTAs are passionate about helping people live their lives to the fullest, and incorporating sleep health into physical therapist practice is an opportunity to do that in a holistic way.”
“If you understand the human system and all that influences it — including sleep — you can work with anyone in any setting. It’s not that sleep is going to open up more areas of employment for physical therapists and physical therapist assistants; it’s more that you bring value to your clinical expertise if you understand how to measure, track, and influence recovery,” says Perry Brubaker, PT, DPT, owner of Brubaker Prevention & Health Promotion, in the greater Atlanta area. “Historically, PTs have been involved in sleep by mostly looking at how it is affected by musculoskeletal injury or pain.” That is changing.
Diversity, Equity, and Inclusion
Sleep health aligns with APTA’s focus on diversity, equity, and inclusion. As Schuft explains, “When you help people with their sleep habits, you see inequities and challenges that can be major barriers to their quality of sleep. Some pillars of sleep hygiene are a privilege to have, such as a consistent work schedule, a separate room in which to sleep, safety, even just having less noise at night.”
On the flip side, Schuft continues, “people might be working swing or graveyard shifts. They might live in a studio apartment or a trailer. Some people don’t have a bed to sleep in. Many people are constantly dealing with persistent, systemic stressors that keep their nervous system on high alert and inhibit their quality of sleep or ability to sleep at all. Even though there can be major barriers, any little help or guidance from a physical therapist to help maximize what people can control can be helpful to improve sleep and thus their quality of life.”
Berner agrees. “Think of the difference in sleep quality between an individual who lives in a lower socioeconomic area with a train or rail in their neighborhood and a person living in a quiet suburban community,” he says. Being aware of these differences can enable PTs to better advise their patients or refer them to the resources or health care providers they need.
Sleep Health and the Pandemic
According to Brett Neilson, PT, DPT, COVID-19 has taught everyone a great deal — including that healthful behaviors are crucial to overall health. The CDC says that “staying healthy during the pandemic is important” and, specifically, “remember the importance of staying physically active and practicing healthy habits to cope with stress.”
“Individuals with more comorbid conditions are at higher risk for contracting COVID-19 and experiencing more severe symptoms,” Neilson says. PTs can help address some of these conditions, such as overweight and obesity. In addition, Neilson says, “There is a strong link between sleep and the immune system. Optimal sleep quality and quantity provides protection against illness and infection.” Neilson is director of admissions and assistant professor at Hawaii Pacific University, College of Health and Society, DPT program.
It’s possible that sleep also may have an impact on the effectiveness of vaccines. Neilson cites a 2002 article in JAMA, “Effect of Sleep Deprivation on Response to Immunization,” that found that sleep has a profound impact on the body’s response to the flu vaccine. “Healthy individuals who had their sleep restricted to four hours per night for six nights produced less than 50% of the immune reaction compared with their well-slept counterparts who had on average 7.5-8 hours of sleep. A 2011 study in the Journal of Immunology found similar consequences of too little sleep for the hepatitis A and B vaccines,” explains Neilson. A February 2021 letter in the journal Sleep and Breathing, “Advice for COVID-19 Vaccination: Get Some Sleep,” suggests that sleep may have a similar benefit for people who will receive COVID-19 vaccinations. Further, Neilson suggests, “Advice should be given to the general public to focus on their sleep, nutrition, and exercise levels. These are also the behaviors that may lead someone to recovery from COVID-19.”
Telehealth and Sleep Issues
During the pandemic, telehealth has been beneficial for certain health care providers. While PTs often must work with their clients in person, sleep health has been one area in which telehealth can be even more helpful than in-person interaction. “Talking about sleep health with people is incredibly easy to do via telehealth because it feels like a conversation,” Schuft says. “You can have a list of sleep habits to run through with patients and clients and take note of their answers. One nice thing about telehealth is that the person typically is in their home, and you can see their physical sleep space. They can show you how they typically lie down at night, the support of their pillow, and other elements of the sleep environment. It lends itself to problem-solving their physical space.”
Looking to the Future
With APTA’s existing and developing resources on sleep issues, the future of PTs working in sleep health seems bright. “Sleep health has tremendous effects on our patients’ health and rehab outcomes. If we want to be ‘movement experts,’ we need to care about everything that influences movement,” says Berner.
“My hope,” says Neilson, “is that physical therapists and physical therapist assistants recognize the importance of proper sleep, and that they will increase conversations with their patients and clients about the importance of sleep health and will equip themselves with tools to help them achieve more optimal sleep. Finally, all physical therapists should be able to screen for the top three sleep diagnoses — sleep apnea, restless leg syndrome, and insomnia — and provide sleep health interventions to include sleep education, positioning strategies, and movement.
“Research is clear that poor sleep is likely a stronger predictor of pain than pain is a predictor of poor sleep,” Neilson adds. “What this means is that for patients who struggle to get moving or for whom physical therapist interventions are not working, be sure to ask about their sleep. Often, we need to set the foundation of health before we can move forward with recovery.”
Authored by Michele Wojciechowski for the American Physical Therapy Association (APTA). Michele Wojchiechowski is a freelance writer.
Quick Sleep Facts
75 minutes of high-intensity exercise or 150 minutes of moderate-intensity exercise per week has been associated with reduced levels of daytime sleepiness and better concentration, even when someone is tired.
Source: “Association Between Objectively-Measured Physical Activity and Sleep, NHANES 2005–2006.” Mental Health and Physical Activity, December 2011.
About 80% of people who take prescription sleep medications experienced residual effects such as oversleeping, feeling groggy, or having a hard time concentrating the next day.
Source: “Residual Effects of Sleep Medications Are Commonly Reported and Associated with Impaired Patient-Reported Outcomes among Insomnia Patients in the United States.” Sleep Disorders, December 2015.
Almost half of all Americans say they feel sleepy during the day between three and seven days per week.
Source: “2020 Sleepiness and Low Levels of Action,” Sleep Foundation.
After adjusting for age, insufficient sleep by race and ethnicity shows clear differences, with 46.3% of Native Hawaiians/Pacific Islanders, 45.8% of Blacks, 40.4% of American Indians/Alaska Natives, 37.5% of Asians, 34.5% of Hispanics, and 33.4% of whites reporting getting less than seven hours of sleep.
Source: “Short Sleep Duration Among US Adults.” Data and Statistics. Centers for Disease Control and Prevention, May 2017.
35.2% of all adults in the U.S. report sleeping on average for less than seven hours per night.
Source: “Short Sleep Duration Among US Adults.” Data and Statistics. Centers for Disease Control and Prevention, May 2017.
Adults aged 18 to 64 need seven to nine hours of sleep per night. Adults over 65 need seven to eight hours.
Source: “How Much Sleep Do We Really Need?” Sleep Foundation, September 2020.
Insufficient sleep has an estimated economic impact of over $411 billion each year in the United States.
Source: “Why Sleep Matters-The Economic Costs of Insufficient Sleep: A Cross-Country Comparative Analysis.” Rand Health Corporation, June 2017.
Drowsy driving is responsible for more than 6,000 fatal car crashes every year in the United States.
Source: “Drowsy Driving: Asleep at the Wheel” Sleep and Sleep Disorders. CDC, May 2020.
People with severe insomnia are seven times more likely to have work-related accidents than good sleepers.
Source: “Medical and Socio-Professional Impact of Insomnia.” Sleep, September 2002.
Women have a lifetime risk of insomnia that is as much as 40% higher than that of men.
Source: “Sex Differences in Sleep: Impact of Biological Sex and Sex Steroids.” Philosophical Transactions of the Royal Society B Biological Sciences, 2016.