HEALTH
As many of us are aware, sleep is very important for optimal health. Recently, this topic has been getting more coverage in the media as a growing area where most of us are not getting the right amount or right quality sleep. In our world of sports and orthopedics at OrthoRI, we often hear patients complain that they cannot sleep due to pain. As a physical therapist, I have the beauty of spending a lot of time with patients and when this complaint continues over the course of care, it can feel quite frustrating not knowing how to help. In my search to help give these patients advice, I stumbled upon a recent article that can help physical therapists give better advice and a better idea of when these patients should seek care from a specialist in the world of sleep. The article titled "The Pain of Poor Sleep: A Clinician’s Guide to Assessing and Addressing Sleep Dysfunction in People with Musculoskeletal Pain Conditions," published in JOSPT Open (2025), provides a realistic framework for physical therapists and other clinicians to integrate sleep health into the management of musculoskeletal pain.
One of the core components of the article is the bidirectional relationship between sleep and pain. It is basically a “two-way street”. When someone cannot sleep because it is disrupted or insufficient (typically less than 7-9 hours) they can develop an increased sensitivity to pain or, in nerd speak, they develop hyperalgesia. This lack of quality sleep can impair the body’s natural ability to inhibit pain. On the flip side, a patient can have pain which hinders their ability to get quality sleep. We often see this with acute injuries or with our post-operative patients. Persistent pain often interferes with sleep quality and duration, creating a cycle that hinders recovery. If the patient continues to have difficulty sleeping, it can lead to a host of other problems down the road. Chronic sleep deprivation is a predictor for developing chronic pain and is linked to cardiovascular disease, diabetes, and mental health issues like anxiety and depression. This is no small issue with research showing that about 40% of American adults experience disrupted sleep. Fear not, there are great resources, and this paper presents a nice clinical framework for physical therapists to help assess their patients.
The article presents a nice 3-step screening for assessing sleep dysfunction in those with pain conditions. The first step is really simple and could easily be integrated into the physical therapy intake form during the initial evaluation.
3 simple questions:
How many hours do you typically sleep?
Do you feel well rested during waking hours?
Would you say your overall sleep quality is very good, fairly good, fairly bad, or very bad?
If the patient answers that they sleep less than 7 hours or does not feel well rested, or if they rate sleep as fairly or very bad, you will move onto step 2. In step two we are trying to discern whether or not the patient has true sleep dysfunction or if it is more related to a pain condition. Here we ask the patient if their pain condition is impacting their sleep. If sleep issues were present before acute pain conditions or if it appears that pain is not impacting their sleep, they will move into step 3. Step 3 looks at the “big three” sleep conditions. This step is looking at Insomnia, Restless Leg Syndrome, and Sleep Apnea. This step has 4 questions, and they can help us tease out if the sleep issue is one of the 3 conditions. Based on answers to these questions, there are nice outcome measures we could use as well as a referral to a specialist in the respective fields. The article has a great infographic/algorithm that you can use to help get from the basic sleep questions in step 1 to the more specific impairments in step 3.
Lastly, the article provides some interventions that could be helpful to improve sleep in people with musculoskeletal pain. The article emphasizes that while "sleep hygiene" (e.g., keeping the room cool/dark) is helpful, it is often insufficient on its own. Instead, it highlights Cognitive Behavioral Therapy for Insomnia (CBT-I) principles across four domains:
Reducing Pre-sleep Arousal (wind down to drift off)
-- Reduce looking at stimulation or distressing content while in bed (news, social media, email, etc.)
-- May need to move mobile devices from reach of bed
-- Do not use bed for activities that stimulate the brain (worrying, problem solving, doing work)
-- Practice relaxation techniques during day and before bed
-- Develop relaxing bedtime routine and be consistent.
Increasing Sleep Drive (stay up to sleep well)
-- If not sleeping after 30+ minutes, get out of bed and do something relaxing in dim lighting and only go back to bed when feeling sleepy again.
-- Work to avoid naps, however if a nap is needed limit to 15-60 minutes
-- Engage in exercise/physical activity during waking hours (avoid vigorous exercise within 1 hour of bedtime)
Entraining Circadian Rhythm (set your internal clock)
-- Have a consistent sleep schedule
-- Create a consistent schedule during waking hours
-- Strategize exposure to light
Promoting Sleep Hygiene (prep right to sleep tight)
-- Making sleeping environment comfortable, cool, quiet, and relaxing
-- Avoid eating a large meal or spicy food 2-3 hours before going to bed
-- Avoid/limit alcohol consumption
-- Avoid caffeinated foods/drinks at least 4 hours before bed
-- Avoid excessive liquid 2-3 hours before bed
-- Making using the bathroom as safe and easy as possible (lamp within reach, night lights, etc)
Key Takeaway for Patients and Clinicians
Physical therapists are uniquely positioned to address sleep because they spend significant time with patients. Addressing sleep dysfunction is not just about "feeling rested"; it is a parallel driver of recovery. Improving sleep can directly decrease pain intensity and improve the overall trajectory of rehabilitation.
Reference:
The Pain of Poor Sleep: A Clinician’s Guide to Assessing and Addressing Sleep Dysfunction in People With Musculoskeletal Pain Conditions
Mark H. Shepherd, Brett D. Neilson, and Catherine F. Siengsukon
JOSPT Open 2026 4:1, 12-22
Great resource and has sleep study center locator:
https://sleepeducation.org/sleep-center/
