Low back pain. We’re going to talk today about one of the key drivers of low back pain that I hear almost no one talking about in the movement and rehab world.
So, this is not about your muscle strength, it’s not about your back strength, it’s not about your core strength, it’s not about your mobility, it’s actually your sleep. Poor sleep has been shown in the research literature to be one of the biggest drivers for low back pain.
Now, let’s talk about this, what it means, and I’ll give you some basic ideas about what to do about it. Back in 2014, a super interesting study was published, and what they did is they took people with chronic low back pain and they gave them a sleep scale and a pain scale. So, basically, they had a sleep scale that was zero to three, and that was their rating for how well they slept the night before.
Zero was really good sleep, three was terrible sleep. And then they said, okay, your pain level then is zero to ten. And what they found was that for every point change in sleep quality or how they felt after sleeping, their pain levels increased by two to two and a half points. So, basically, what they found was that a good night’s sleep, going from like a three terrible sleep to a zero, was actually changing their pain scores four to six points.
Now, why that’s really, really important to understand as a movement and rehab person is that most therapy interventions, when you look at them in the real world of research, in the real world of application, perform half that well. What the heck does that mean? It means that better sleep may be twice as effective or even three times as effective as most physical therapy or chiropractic or whatever interventions for low back pain. That should make you take a second and stop and think and wonder for yourself or for your patients or clients, what the heck are we actually doing whenever it comes to low back pain? All right, so whenever I get in this kind of discussion, people will say, well, I thought Z-Health was a brain-based company, and I thought you guys just talked about neurology. I’m going to give you some real key reasons why we talk about this and why this is our broad approach. We look at things from a systems perspective.
Whenever we talk about sleep, people say, okay, well, if sleep is such a big deal for getting people out of low back pain, then what does that mean? What is good sleep? This is where things get really complicated because if you can dig into the sleep research and you read this expert versus this expert versus this one, you will start to figure out very quickly that there is not a ton of agreement on what is optimal. I’m just going to give you some ranges. Right now, when people talk about the quantity of sleep, you’re going to see most research saying you need between six and eight hours per night to achieve better health outcomes. In the largest meta reviews out there, people will find that the lowest mortality risk associated with sleep is seven hours. But then they go, okay, well, what we’re actually seeing is that six to eight seems to be okay, seven seems maybe the best. If you’re sleeping nine or 10 hours, things get worse again. Under six and past nine, both those ends of the spectrum are potentially problematic from a overall health and mortality perspective.
Now, why is there this range? Well, because people are different. More importantly, these studies that have been going on for a long time, now they’re getting their turn on their head because what they’re figuring out is that if someone sleeps sporadically seven to eight hours, like two or three times a week, they get seven, eight hours, but the other nights they’re sleeping five, they are not as healthy as someone who sleeps six and a half hours every night. They are now starting to talk more about the consistency of our sleep than the actual specific time, because they’re getting a lot of factors that play into that.
Now, from a Z-Health perspective, whenever we talk about sleep, we say you have three buckets that you have to look at. You have to look at the timing, you have to look at the quality, and you have to look at the quantity. What we just talked about was the quantity aspect. Timing is really about when do you go to sleep, and the quality is often about the preparation that you do before you go to bed, and then how well you’re sleeping when you’re there. Now, why all this ties into low back pain is that whenever we have a timing issue, a quality issue, a quantity issue, over time, that impacts the nervous system. It impacts it dramatically, because our inflammatory markers will go up. We see changes in oxygenation to the brain. There are a lot of different things that happen, particularly in our neurotransmitters, like our dopamine system, that are impacted whenever we have poor sleep. Whenever we start to now think about that concept in relation to what we know about low back pain, particularly chronic low back pain, which is that it’s a brain-driven issue, not the muscles or the joints, all of a sudden, our emphasis on doing core activation and core stability and breathing exercises and mobility exercises, while all important, they may not fix everything.
Perfect example of this, many years ago, I had a client. She was a professional basketball player. This was long before I knew a ton about neurology, but she was a pro basketball player. She’d been diagnosed by MRI with an L5-S1 disc herniation. She had sciatica down one leg, and so she was playing still, but she was struggling with pain all the time. I started seeing her after she had had a ton of chiropractic and physical therapy interventions. Nothing worked. She’d feel a little bit better for a couple of days, and then as soon as she went back to playing or whatever, she would feel worse. Then when I started talking to her more about it, I was like, well, what else is going on? She started telling me that she was fatigued and that she didn’t sleep well. At that point, I didn’t really, again, know that much about neurotransmitters and how all this stuff worked, but I did know enough to say, hey, you know what? Let’s at least look at the basics. We did blood work on her, and what showed up really, really quickly was that she had iron deficiency anemia. Very quickly, we started treating her iron deficiency anemia just with supplementation and changing her diet a little bit, and here’s what happened. Two weeks after we started working with the anemia, I saw her again. How are you doing? I’m doing fantastic. That’s crazy. What do you mean fantastic? She’s like, my pain is gone. I said, your pain’s gone? She said, yeah, it’s completely gone. I’m playing normally. I feel a ton better. Then as I explored this more with her, she told me, yeah, I actually, like three days after I started supplementation, I started sleeping because she was waking up through the night. What eventually, as you get deeper in neurology, what you start to learn is that whenever you have iron deficiency anemia, it impacts the brain. It impacts dopamine signaling. It impacts more neurotransmitters. Iron deficiency makes it harder for the brain to get oxygen, et cetera, et cetera.
Whenever we talk about Z-Health, about back pain from a Z-health perspective, this is how we look at everything. It is not just about, hey, I need to do another nerve glide. Hey, I need a cooler mobility drill. Those all can play a role, but systems thinking means that we have to look at everything from a brain perspective. If the brain is not getting what it needs and it’s not getting a chance to rest and deal with draining its own lymphatic issues, and we have increased inflammatory activity in the body, all that happening from poor sleep, that can be a big driver for a low back pain.
If you work with people with low back pain, you’ve got to ask them how they’re sleeping. If they are not sleeping well, you can coach that yourself. It is also really recommended that you have sleep experts on your phone that you can refer people to because sometimes sleep is complicated, but I think it is a huge miss in the movement and rehab world to talk to people about low back pain and give them all kind of cool interventions without maybe solving the one thing in the literature, at least, that may be more effective than anything else we have them do, which is their sleep.
If you are a movement professional of any kind, a doctor, a therapist, a movement coach, Pilates, yoga, whatever, and you’re interested in bridging the gap between what you do with modern applied neuroscience, we would love to chat with you. You can go to the pinned comment. You can email us. You can set up a phone call. This is the kind of stuff that we spend our days obsessing about. How do we make every patient, every client that we work with better? That means we have to know every system and know it really, really well. If that’s of interest to you, get in contact. Otherwise, good luck.
