521- Back Pain as a Predictor of Poor Sleep Health

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are talking research. This one is all about low back pain and whether it is causative or correlative to poor sleep. This is a six year study. A lot of take home messages, clinical pearls and application in your practice. Before we get started, I want to say a few words about Leander Tables. You can save $1,000 on their series 950 for being a listener on this podc. Please check them out at leandertables. I'll also drop a link down in the show notes. Now is the perfect time of year to step up your table game. Additionally, blue honest lasers, $2,500 off their Pro VX laser. This thing is awesome. It is full spectrum. They're a new partner. Please go connect with their team, support them and get a discount in the process. All for being a listener of this podcast. Now, as I said at the top, today's episode, all about research. The title of the study, back pain precedes sleep problems in older Men. Maybe that's a title that says it all, but we're gonna dive deeper into what they found and additionally how it applies to people in your practice. So what if I told you that back pain today could predict your patient's sleep problems not tonight, not next month, but up to six years from now. Yes, you heard that correctly. Six years. Well, that is the headline from this study. It's a longitudinal study and they tracked older men over time and found out something that I think you're gonna believe is really important and that is back pain predicted future sleep problems. But. But sleep problems did not predict future back pain. That is a big deal because this is not. Oh, my back hurts so I slept a little weird last night. This is your back pain today alters, literally alters the trajectory of your sleep for years. And as I said, today we're gonna break down exactly what the researchers found, how they found it, and more importantly, how you can use this when you speak to your patients during a report of findings and creating educational content. So this research comes from the Osteoporotic Fractures in Men study with a well known MROs cohort. Researchers found, followed, excuse me, over 1,000 older men, all 65 and up across two sleep visits, very detailed sleep visits, about six years apart. And what they wanted to know was, is the relationship between back pain and sleep problems bidirectional? Does it go both ways or does one typically come first? And I think as a chiropractor, I'm not gonna say anything you don't know in terms of the fact that we both know for years that sleep and pain are linked. But most of that research is what they would consider to be cross sectional. It's based upon self reporting and it's focused on a single sleep metric like duration or quality of sleep. This research team looked at things differently. This is a multidimensional sleep study and they utilized a sleep health model measuring things like regularity, satisfaction, alertness, timing, efficiency and duration. And of course, some of that came from self reported mechanisms, but a lot of it came from objective sleep data. So there are multiple kind of types of back pain. And every four months, participants were asked to report if they had any back pain, if they had frequent back pain, defined as three consecutive reports, so to speak, of back pain, whether they had severe back pain, or whether they had activity limiting back pain. And this is important because it let the researchers look not just at like, do you have back pain? But whether the severity, whether the frequency, or whether the functional impact changed the results. And you know, this wasn't just correlation. They used what they call cross lagged panel modeling to test whether back pain at time number one predicts sleep issues at time number two, or whether sleep issues at time number one predicted back pain at time number two. And that's really the heart of this study and why it's so unique. And where it gets good is when we start to dive into some of these key findings and statistics across all categories of back pain. All categories of back pain, the results were really, really consistent. Back pain at baseline predicted more sleep problems six years later, and sleep problems at baseline did again not predict more back pain later. So any back pain, any back pain increased sleep problems by 12% six years later. So this was not just like 1 or 2%. This is meaningful. Now, frequent back pain predicted sleep issues at a 17% clip. Six years later, severe back pain that went up to 19%, activity limiting back pain over 25%, more sleep problems. So the worse the pain, the worse the sleep outcome was even years later. And what's interesting to me is the activity limiting component of this. Again, we said any back pain, frequent back pain, severe back pain, or activity eliminating, limiting. Excuse me. So somebody might not have reported severe back pain, but it was activity limiting. And therefore that was a really predictive index of what was to come with sleep. So they might have said, this is mild, but it's activity limiting. On the other side, they might have reported severe back pain. However, it was not activity limiting and that reduced the likeliness, so to speak, of sleep problems later. So this again, it just showcases the fact that one, when we talk about where are you at on a 0 to 10, that's subjective, right? Pain scales, and even when this isn't exactly a pain scale, but any back pain, frequent, severe, it's really more important. Is this limiting your activities of daily living? Is this changing the way you do things? Is this limiting the fun you're having? Is this limiting your ability to do your work? Is this limiting? All of these things that are activity limiting are really some of the most important questions that we can be asking. And again, with the reverse pathway, none of the sleep measures predicted future back pain. Not duration, not timing, not alertness, not satisfaction. It was a complete shutout. So from a clinical perspective, this is really, really huge because it starts to showcase that sleep problems, at least in this study, they were not random. You know, back pain primarily predicted poor sleep satisfaction. Number one, older men with back pain, they were far more likely to report being unhappy with how they slept years later. Poor sleep timing, not duration, but timing, meaning irregular sleep and wake cycles or sleeping too early or too late. And this suggests a pretty significant behavioral or a neurologic, and I should say a neurological shift, not just that the pain keeps me up, it's literally changing their timing and how they're cycling their sleep. Now, what didn't change? Couple surprises here. Duration did not change. Daytime alertness did not change. Wake after sleep onset did not change. Sleep efficiency did not change. None of those were meaningfully influenced by back pain. So the stereotype of, ah, my back was hurting so I couldn't sleep at all isn't exactly what was happening here. Instead, pain seemed to really degrade sleep satisfaction. Again, it shifted sleep timing and it created ultimately long term sleep health deterioration. And this held true after controlling for age. Bmi, chronic conditions, depression, activity levels, medication, alcohol, smoking, cognitive function, all of that could basically be normalized. These all held true across all of those. So for us as chiropractors, this is important because this is where we can bring our clinical practice into play. Back pain is not just a daytime problem, it's a long term sleep disruptor. And when patients come in with back pain, they're not just dealing with pain, they're potentially Setting up years of sleep issues. And we all know that poor sleep has influence on inflammatory cycles, influence on slower recovery, influence on more pain sensitization. And that's a really vicious cycle. Excuse me, that starts with the spine. So this is delicate because you don't want to scare people for the future. But it also is important to point out specifically for those people dealing with sleep issues, getting a really clear understanding of their history and really understanding where they've been at. And for those people with pain today and sleep issues not yet, really helping them get out of pain, number one, as quickly and as efficiently as possible, helping them stay in acute pain and not transition over to chronic pain. And my brain goes seven ways from Sunday with this as well. When you start to think about them needing your care, we know that a lot of times medications can cause specifically pain. Medications, digestive issues, sleep issues, all of these things that ultimately trace back to furthering the cycle of poor sleep cycles. Right. So it's really important, it is really important that patients coming into your practice get the care they need and don't go on to interventions that they don't need. Of course, there's the exception where somebody comes in and they just need some advanced interventions, but that is the exception. It's not even remotely close to the rule. So. And it's, and it's not just, oh, well, I don't want them to go down that path because it's good for my business. Not at all. This is about their health. And if they're going down that cycle of, outside of your practice, it's very likely that they're gonna come back in really unhappy at a certain point in time. So helping people understand that the natural way to go about this, that movement based care, that what you provide, if it is, and quite often it will be what they need, is really, really important. It's also important to keep in mind that sleep interventions alone may not resolve back pain. So since sleep problems did not predict later pain, simply telling a patient to sleep better might not move the needle on back pain. But helping patients improve or resolve their back pain can improve sleep months or years from now. Again, this is massive. It's a massive value proposition for your care. You know, spine health doesn't need to be only about pain relief or only about mobility. There is a lot of downstream effects, and we've seen this with the multidimensional mechanisms of action. But there's impact on sleep, on mood, on cognition, on function, on even long term aging. So this really reinforces, I think, a Core concept of chiropractic, which is spine health, is really central to healthy aging in many, many, many ways. And again, I'll just highlight that activity limiting pain had the strongest effect. So that means that the moment the pain began to interfere with function, walking, daily tasks, exercise, the long term sleep risk skyrocketed. So when you hear a patient say it's not that bad, it's important to highlight that the earlier that this is addressed, the better their long term sleep health will be. And that's a really powerful motivator. So you know, letting people know about this information during maybe a report of findings in your practice. Obviously this is great patient reactivation messaging in marketing content that goes out online during active care plans and with seniors as well because that population is especially vulnerable to declines in both sleep and functional ability. So it's a really, really great opportunity for, for some fantastic patient education that is really helpful for people. So the big takeaway in today's episode is that back pain is a predictor of long term sleep problems. This showcases it. But poor sleep does not predict back pain. So addressing back pain early, that matters. Improvements in pain can absolutely improve sleep satisfaction and timing years later. So ensuring that they're getting the care that they need early critical and sleep interventions alone may not change the pain trajectory. So this was a powerful study. I really liked it. I think it's a, it's a great opportunity to springboard the intersection of pain and sleep in further studies because of how it was not scripted but how the different pain aspects and sleep aspects were measured and how it was multi dimensional. I think that's really, really important and impactful as time goes on. Now, as we wrap up today's episode, big shout out to Shockwave Centers of America. They're going to hook you up with $500 and a free cart. Shockwave Centers America Dr. Dan, fantastic resource. I will drop that link down in the show Notes and Neckcare, the best objective assessment of the cervical spine in the marketplace. Awesome hardware software combination. Neckcare.com they'll hook you up with 10% off. So thank you so much for tuning in each and every week. Thank you for being a chiropractor. I hope you have a fantastic week in practice and I will talk to you soon.

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