Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Is Sleep the New Treatment for Pain? | Associate Professor Michelle Hall
113 Plays18 days ago
Could the key to easing chronic joint pain lie in how you sleep?
In this episode, Lachlan Townend talks with Associate Professor Michelle Hall from the University of Sydney's Musculoskeletal Research Hub. They unpack what osteoarthritis really is, why your X-ray often doesn't match how you feel and why myths like "bone on bone" and "exercise wears the joint out" don't hold up.
Then they turn to sleep — why poor sleep doesn't just follow pain but can actively drive it, how cognitive behavioural therapy for insomnia (CBT-I) helps most people within weeks, often without medication and what Michelle's clinical trials could mean for the future of pain care.
If you live with pain, or treat people who do, it's a practical and hopeful listen.
Resources
- Is sleep contributing to you or your patients' pain? Try Pain Coach for free and find out: Click here
- Lachlan Townend on LinkedIn: https://www.linkedin.com/in/lachlan-townend/
- Michelle Hall on LinkedIn: https://www.linkedin.com/in/michelle-hall-548627111/
- Michelle's research profile: https://profiles.sydney.edu.au/michelle.hall/about
- Musculoskeletal Research Hub, University of Sydney (Charles Perkins Centre): https://www.sydney.edu.au/charles-perkins-centre/our-research/research-groups/musculoskeletal-research-hub.html
- Musculoskeletal Research Hub on LinkedIn: https://www.linkedin.com/company/111559366/
- Online sleep resources based in cognitive behavioural therapy for insomnia (Sleepio): https://sleepio.bighealth.com/
- SLEEP-FIT Trial (sign up): https://redcap.sydney.edu.au/surveys/?s=AKTTJLD44NNMYMHK
- Referenced paper (open access): Klyne DM, Hall M. Is sleep the new treatment for pain? Two issues need resolving before deciding. Sleep. 2024;47(6):zsae089. https://doi.org/10.1093/sleep/zsae089
Key Topics:
00:00 Intro
01:19 Michelle's path into research
04:00 Why her dad's pain started it all
08:23 From biomechanics to the whole person
13:04 What osteoarthritis really is (and why scans mislead)
19:52 Myths, exercise & weight loss
27:57 Why sleep matters in pain
31:14 Is sleep the new treatment for pain?
34:16 CBT for insomnia, explained
43:52 Inside the trials
52:07 Beyond knees: other pain
55:24 Where to start
57:23 One habit from lasting relief
58:20 Find Michelle
Disclaimer
This podcast is for educational purposes only. The views expressed do not constitute medical advice and are general in nature. Please obtain specific advice from a qualified health professional before acting on any information in this episode.
Recommended
Transcript
Introduction and Personal Influence
00:00:00
Speaker
I remember sitting outside the office of the doctors with my dad seeing these these names on the door. And then here they were with projects that I could do with them. So I was kind of like, okay, this may be what life's calling
The Role of Sleep in Pain Management
00:00:13
Speaker
me to do. We wrote a paper that I read just last night. Is sleep the new treatment for pain? Most of us can relate to, oh, I'm sore. I just didn't sleep last night because was sore. But actually the evidence is becoming very clear that poor sleep can make your symptoms worse. And it may be a bit controversial to say this, but maybe we try sleep to fix and sleep before we look at exercise. and That's what our trials are at the moment to see if we can get better effects when you do the two together.
00:00:41
Speaker
This podcast is not personalized medical advice. Consult a health professional before acting on anything discussed. Just give me 30 seconds before we start. Whether you're a clinician wanting better outcomes for your patients, someone living with chronic pain or supporting someone one who is, thank you for being a loyal listener.
00:01:01
Speaker
Most regular listeners haven't hit follow yet. If that's you, please tap it now. It tells the algorithm to show this to more people it can help. And that's the single biggest thing you can do to help me and my guests on our mission to create a world with a little less pain.
Speaker's Journey and Research Focus
00:01:19
Speaker
Michelle, it's been a bit of an Irish takeover on the podcast lately. i had Merv Travers and then I had Niamh and Barry um from Curtin University and and now yourself. What is it about the Irish that leads them into research?
00:01:37
Speaker
Yeah, it's ah it's a great question. Thanks so much, Lachlan, for having me on your show. and Yeah, i growing up in rural Ireland, i I never knew about research. I never really knew it was a pathway at all until I went to a university in Dublin and I did exercise, sports science and health it was called at the time.
00:01:56
Speaker
And um funny enough, my mentor, the head of school at the time, we found out afterwards that his father used to deliver chicken meal to my grandfather on the farm.
00:02:07
Speaker
And he was really, really kind to me. And he he had me an honours project with a couple of other students with a surgeon who had done my dad's knee replacements and my granddad's knee replacements. And I just, i just as they say, got the bug with the research. and You very rarely find...
00:02:26
Speaker
all the answers that you want but you find enough to keep you coming back and wanting to know more and yeah so I you know he said I was walking around like a Cheshire cat so I suggested that I keep going with the research pathway and I was pretty intimidated by a PhD I was like oh no I'm not fit for that I'm not ready for that and so he's like go go to you the U.S. do a master's and he wrote a list of all these unis at universe in the U.S. s and I picked out Iowa and he was like I come back in on Monday and he's like why do you pick out Iowa as the armpit of America and
00:03:04
Speaker
it' like I thought it was kind of the one that maybe would feel the most like home. You know, it was kind of small, rural relative to to to some of the bigger cities. and But I was fortunate enough and got a place there and did two years in kinesiology program. And absolutely loved it. Really, really did. And as I say, my my love for research just kind of kept growing. And I was fortunate enough then to get a PhD position at Melbourne Uni where Professor Kim Bunnell was leading research programs around osteoarthritis, knee osteoarthritis and just pulling off these amazing trials, like fantastic around exercise, how exercise could help people. No problems with recruitment, which was something I was struggling with, with my little master's project. So, and yeah, I was very, very fortunate and and spent the time in Melbourne until about three years ago. We we moved to Sydney.
00:04:00
Speaker
ah Cool. Awesome. Awesome story. Tell me, how did your, was there something about your dad and granddad's experience that led you into sort of knee osteoarthritis kind of research area?
00:04:14
Speaker
A hundred percent. and So I went into sports science, sports mad, right? I loved all the things about sports. And kind of as you went progressively through the degree, you realized that, you know, exercise science, exercise physiology, biomechanics, you could actually help a lot more people than the elite sports people as um as you know, as attractive as that is.
00:04:37
Speaker
And so when the honors projects, you know, the professors kick up different projects. So when the one came up around osteoarthritis, and I knew it was in association with Kappa Hospital. I was like, okay, that's that's the one I want to do because I remember sitting outside there the office of the doctors with my dad seeing these these names on the door, and then here they were with projects that I could do with them. So I was kind of like, okay, this may be what life's calling me to do.
00:05:04
Speaker
Yeah, that's awesome. And was there, you know, your dad or your granddad's journey, was there something that you were like, man, we're not doing this well enough or was there a curiosity or what was it that kind of got you thinking, ah this, yeah, I'd love to go down this this pathway?
00:05:23
Speaker
Yeah, like it's it's interesting you say that. I think it kind of happened reverse for me. It wasn't, like when I was growing up, my dad was diagnosed with osteoarthritis quite young, you know, so he had his joint replacement in his 30s. So he was farmer and as my granddad was. So, you know, definitely in the case of my dad, it really was tough for him. it was very, he was very frustrated that he couldn't do the things that he felt he should be able to do as a young man and to do things with the kids. And he'd be really sore, you know, and there would have been days I was off school because I get to help him, which, you know, I loved as a, you know, as a real daddy's girl. So it, that, but it never was like, oh, I want to do something to fix this.
Understanding Osteoarthritis: From Biomechanics to Systemic
00:06:05
Speaker
I never really thought that I could, I never saw myself in those positions that I could, help people like that but I think growing up and being exposed to that I can really i can re relateyed especially to people with and lived experience i can relate I can relate to the carers or the people around them and how much it actually does affect families and it I think yeah it was really tough at times for him especially t during those really
00:06:33
Speaker
acute pain period, you know, and at that time it took maybe two weeks to get a joint replacement. So you had to figure out how, how to make everything else run well, you know, at the same time, you know, obviously my mom was a great support at that. But so then when those opportunities came up that you could do research in this space, Oh, maybe, maybe there are things I could do to help. And, and it was kind of like marrying these two areas that I loved exercise sports. And then, you know, you kind of got your,
00:07:01
Speaker
the passion that you've seen and the area where you could apply it o yeah interestingly i um i kind of share that with the sport idea because like when i was studying physiotherapy at griffith here i actually in my last year i was a sports trainer for the gold coast suns the afl team up here And I thought, oh, this is exactly, you know, this is what I want to do. and then And then being around it for a while, I was like, maybe it's not actually. Maybe the the trade-off of the travel and et cetera is not worth it to to help people run a little faster or jump a little higher.
00:07:39
Speaker
um And, you know, the the the impact that you can have on a life is, in my opinion, far greater in other areas of physiotherapy and it sort of led me away from that.
00:07:50
Speaker
But yeah, interesting. I kind of, I share that passion and, and then I've sort of drifted elsewhere throughout my career. Um, i've I've noticed that your research has taken a bit of ah an arc or like there's been a bit of a trajectory initially with biomechanics, how the knee loads with certain movements, et cetera, and then more to some of these bigger picture things, whole person, it's sort of complex systems approach into sleep, which I think will help.
00:08:23
Speaker
hopefully hone down in on a little bit how did that tell me tell me what led to that sort of journey yeah um and and it I think it has been a bit of a journey um so biomechanics always kind of just made sense to me yeah i mean i mean it made sense okay you've got a sore knee you load it it's sore when you load the knee you know it should be quote-unquote fixed if we can get the biomechanics right it can fix it and That's where I did my PhD on exercises that are maybe similar, maybe to some of your listeners have heard or around the GLAAD program. So we did some, the the trial was really to see if exercises could reduce the loads across the knee when somebody walks by doing these exercise programs.
00:09:09
Speaker
And like for the one for better words, absolutely saw zero change. Like ah when you put everybody together, the average was zero. There was change.
00:09:21
Speaker
We did not change one aspect of biomechanics
Exercise and Sleep: Counteracting Pain
00:09:25
Speaker
and yet people felt better, you know, people reported to be better, but there was, so that was like, okay, of course there's other things to it. and But to do biomechanics research is actually a huge effort. it's It's monumental relative to some things that we can check off by questionnaires. Like people come into the lab,
00:09:49
Speaker
they get all these markers put on them, they're in the cameras, the equipment, the process, and it's just a very, very, very involved. And it just kind of became, I started to doubt whether the the juice was worth the squeeze, so to speak, because of the effort.
00:10:06
Speaker
And then in that sort of, transition of questioning the role and, you know, can I really justify putting this biomechanics research? I don't want to poo-poo all over biomechanics research, but can I justify spending and all this grant money and effort into this when I just started to really question, at least on the average populations, was it was it really worth it I think definitely for some people biomechanics is the the focus.
00:10:33
Speaker
and And at that point, I was actually, I had two kids and the second was not a good sleeper at all. So I was really struggling with sleep. And I was talking to my friend and colleagues from University of Queensland, David Klein.
00:10:49
Speaker
And he was like, we're just having a bit of banter. And he was like, well, keep exercising, you know, because, you know, your exercise will offset the effects of bad sleep on your body, right? was like, oh,
00:11:01
Speaker
Okay, it's hard, David, but you know, okay, thanks. So he started telling me about his research in animal models that was fascinating. When they exposed these animals, this would they kind of gave them an injury and then they exposed them to disturbed sleep, the wheel and the cage, so exercise, and then both. And yeah, those animals that had been exposed to the exercise or the opportunity exercise that it offset the detrimental effects of the disturbed sleep on their transition to what we'll say chronic pain in an animal model where they don't want to put their foot down because they want to avoid, avoid pause of foot ground contact.
00:11:40
Speaker
So that kind of stuck him so so in my mind a little bit. And then I started to dig around in the sleep literature around insomnia. So that's kind of the difficulty of falling asleep, staying asleep and and waking it up early. And when we pulled out the studies that had done cognitive behavioral therapy for insomnia, which is kind of like the first line treatment for insomnia in these chronic musculoskeletal conditions, osteoarthritis and low back pain, lo and behold, we were seeing effects similar to what exercise gets by itself.
00:12:12
Speaker
so And then, you know, it kind of started to make sense as well in the sense that these exercise and sleep disturb the neuroimmune system and they probably have synergistic effects. So that sort of started that trajectory. And then, yeah, we we we were fortunate enough to pick up some grand funding in this. So this is kind of the path that we're on now.
00:12:33
Speaker
No, it's cool. I'm not surprised that you, eat well, it is tricky to pick up grant funding, but because knee osteoarthritis and hip osteoarthritis is such a big problem, I can see why they would like want to put some money into it. um what What is, because I know most of your research is around knee osteoarthritis and and hip osteoarthritis. what What is osteoarthritis for those that are listening going, I've heard this term, but but what actually is it?
00:13:04
Speaker
Yeah, it's a really good question and one that's probably a bit misconceived out there. Essentially, it would, and there's there's different definitions, but I'll give you the one that I think is probably more...
00:13:18
Speaker
Clinically, and maybe your listeners can relate. So it's this idea where you maybe describe that you've go had chronic pain, so ongoing pain for three months or more. And you might have it on most days, not every day. And every we know pain is very variable for everybody. and that it does impact your ability to do function to for everyday activities. So it does, you do feel it when you walk or you do feel it doing stairs or maybe getting out of the car. So it impacts.
00:13:48
Speaker
And then there's another, let's say, criteria is that, you know, your stiffness doesn't last too long. So stiffness, if you do have prolonged stiffness, it it may indicate something else. So that's why they have that in there as part of the criteria. A lot of people think, oh, I need to get an X-ray or I need to get an MRI. and Really, the narrative, the push is in this space over the last number of years is, that you don't necessarily need at all to get an x-y to confirm x-ray to confirm this. And what's really interesting is that what people see on an x-ray and an MRI does not correlate very well with how people feel.
00:14:29
Speaker
And, you know, you might have the most pristine knee on a beautiful x-ray, right? But you feel, it you feel crap. And then that doesn't make sense. It doesn't really validate that feeling for you. Like, well, why am I feeling so bad if the joint looks so,
00:14:42
Speaker
if it don't look so good and then vice versa. You know, we've we've had this a lot of times where we've had participants come in and say, oh, I've seen my x-ray, it's bone on bone and that that's it, right? And then there's this, when you see like bone on bone, I think it's very hard to remove that from your mind. It's very hard to go, okay, well, I'm going to do my exercises or I'm going to follow the advice of the professionals because you've seen, you you know, it's sort of really valid. Okay, that's why I feel the way I do because it's it's bone on bone. But honestly, how you feel is so different to can be so different to what we see. And sometimes I think it's a bit like our teeth, right? The teeth can look great and you might have a toothache and vice versa. You know, your your tooth might look pretty crap, but so far so good, you know?
00:15:28
Speaker
Yeah, I've i actually had ah i had a client come in and had right knee pain, but on x-ray it was, you know, mild. And um on the left it was severe and he had no, or it was moderate or something like that. It had no left knee pain. And it was, you know, like I expect that between individuals, but then within the individual, yeah there was no clear relationship between the amount of and I have to like,
00:15:57
Speaker
double check I had to look at the x-ray twice have they have they labeled this correctly as you left me you know and yeah yeah yeah it is wild and I think most people at least the general public listening would be surprised by that statement so what what else is going on then what why why is that the case if it's not because I think we've shifted from it's all about the x-ray it's all about wear and tear and damage to to something else what else is going on that could be contributing to that pain yeah and this is where I'm going to get very boring on you like it's kind of it's the classic answer it to depends right yeah yeah there's so many things that can be going on for that individual right so We really now appreciate osteoarthritis is not just focused on that joint. As you mentioned earlier, it's the whole person. So, you know, we've had done some work that suggests that there are changes in the brain, you know, and it's how you process that, that feeling. It can be, a lot of it can be driven by inflammation as well. So we also, there's a big shift your immune markers, inflammatory, and it's an interesting interesting space because people think, oh, you can,
00:17:10
Speaker
Is it just one or two markers that can sort of maybe identify or predict or, you know, can we use these markers and bloodstreams to to really target treatments? But we're we're not there yet because it's almost like a constellation of markers and we don't know what that perfect constellation is and for who.
00:17:28
Speaker
So I think, you know, there's a mental component to it. And for some people, it is biomechanics as well. You know, some people really feel that pain during activities and then some people will really feel it at night.
00:17:40
Speaker
um And it's it's quite complicated. And I think this is probably why the field has struggled so much to come up with, you know, really consistently effective treatments.
00:17:52
Speaker
the Yeah, i love I love the nuance there. I think um in my mind there's there's two broad types of pain. There's like the pathoanatomical pain where there's, you know, structural damage and it's still healing, et cetera.
00:18:05
Speaker
But then there's also like, there's also this pathophysiological pain where there's changes in the the way the body systems are interacting that can, you lead to inflammation and things like that. And I think, I wonder whether if you had to put your,
00:18:21
Speaker
you know, flag somewhere, would it be more the, you know, the structural side for you when it comes to knee osteoarthritis? Or would you say that it's it's more about, um you know, these changes within the the the body systems?
00:18:36
Speaker
Or is it a combination of the both? I think I know what your answer is going to be. I think it starts out the former, you know, I think there's something that probably, you know, lot, it's one of the biggest risk factors to develop future osteoarthritis is a knee injury.
00:18:50
Speaker
am and also being overweight and and being a woman. and So I think for a lot of people who've had an injury, it is that initial change. There's something that's happened that maybe sets off a cascade of interactions that we we don't really fully understand yet.
00:19:07
Speaker
And then at some point, and I don't know when that point is, it probably does transition to the to the latter, where it is more of a systems ah involvement.
00:19:18
Speaker
And it's really about... for the scientists to really figure out when that happens and who it happens to, so we can prevent. Because I think right now we're quite reactive and not proactive enough and to to get ahead of this.
Exercise and Osteoarthritis: Debunking Myths
00:19:33
Speaker
and We probably do know enough right now to for prevention, but we it's hard to roll out those those, those programs, you know, and weight loss is a big one or what managing your weight is as big as, as, especially when you've had the injury, I think it's, it's really important.
00:19:52
Speaker
What is, what are some common myths when it comes to osteoarthritis of the lower limbs, knee and hip? Yeah. I think people think, oh if I, if I exercise, I'm going to make it worse.
00:20:05
Speaker
You know, unfortunately, i think, you know, as I said, we've said, you know, you have a look at the x-ray and it just doesn't marry up right? You've got a bone on bone and yet this guy is in front a girl is saying, oh, go exercise. You're like, you know, but that is actually the surest thing we do know. You're better, you're much better to keep moving.
00:20:23
Speaker
am I think we're still getting a handle on how much you need to do and that how much will unfortunately depend again on, on on individual's.
00:20:35
Speaker
But with wearables now, I think we get we we're positioning ourselves to get some answers to that. a The use of you know the watches, how much you're actually doing, the types of exercise you do, and the intensity. There are some trials going on at the moment in Denmark around high-intensity exercise to see if that's maybe a little bit more effective.
00:20:55
Speaker
Because it generally right now, Aerobic exercise seems to have the nudge, especially when you compare it to, let's say nothing or usual care or no treatment. But when you actually compare maybe aerobic exercise to your muscular exercise or to mind body, there's there's no difference between the types of exercise. But at present, it seems to be aerobic.
00:21:19
Speaker
but we did a study last year. So there's much more information out there about the knee than there is the hip. And traditionally, we sort of take evidence from the knee and we go, okay, well, it's close enough. Let's go with the hip. And and unfortunately, it's probably not ah a good good, you do it because you have nothing else to go on, but we need to be more cautious with that. And last year, we published a study where this is specific for hip osteoarthritis, where we had kind of seen that most of the evidence was for resistance exercise, so it's strengthening exercises around the hips and knee muscles. And we added the public health guidelines to get up to 150 minutes of at least moderate exercise, moderate intensity exercise.
00:22:00
Speaker
And We're really pleased to see that physios were amazing to support people to do that and coach them essentially. But there's no difference between the two types of exercise programs. So doing more didn't get you better pain relief or didn't get you better function improvements.
00:22:19
Speaker
But the fact that you could still do it without having more unwanted effects, if you like, was was was encouraging. And also we know that there's benefits of doing aerobic exercise above and beyond resistance as well so from that point of view was good but you know if you've got somebody in front of you that really wants more improvement in terms of their hip pain and function it it didn't seem to achieve that Yeah, this is a common common theme when I talk to to people that have um knee osteoarthritis or hip osteoarthritis is this idea that, but if I do more, it's only going to get worse and wear and tear and deteriorate the the cartilage in that the joint.
00:23:00
Speaker
What what is like that that is our old understanding and i think research has sort of taken us um and you know that always takes a little longer to get to practice and then to the general public so what is the new understanding of of i think we've sort of touched on it but what what is the new understanding of what's going on with osteoarthritis You definitely need movement and load to stimulate the health of the cartilage. So there's like what we call maybe a Goldilocks point. So we know doing nothing is not good and we know doing probably too much and you'll feel it. That's what pain is. It tries to protect you. It's not necessarily a bad thing.
00:23:41
Speaker
But there you definitely need to do some ah to maintain what you have. And ah particularly when we think of who osteoarthritis affects more so it's more women, you know, it develops after 45, typically after 40, it can be earlier, but that's kind of when our bodies change anyway. And we really wanna keep what we have, if not build on what we already have. So definitely this myth of doing more is bad is is not is is not the case for our joint, you know, and there will be a sweet spot
00:24:18
Speaker
i've I've heard that osteoarthritis is more becoming more of like a metabolic
Osteoarthritis as a Metabolic Syndrome
00:24:25
Speaker
syndrome. um Can you explain what that means and and what that might mean for patients?
00:24:32
Speaker
Yeah, no, it's it's a good question. so you know, as we kind of alluded to, knee osteoarthritis and maybe even hip osteoarthritis got a lot of attention biomechanically. But one of the other places osteoarthritis affects us a lot is our hands.
00:24:48
Speaker
So, and, you know, our hands are not really weight bearing. They don't take the loads like our hands do and our, are de sorry, like our knees do and our hips do. So I think this really where that question around what's the metabolic role in this. when we say metabolic, it really means our lipids, ah our high blood pressure. i don't know them i don't know all the criteria for them. and But essentially, it's that cardiovascular, cardiometabolic systems. and that interaction again with your immune markers that really elevates that inflammatory response and we know elevation of these pro-inflammatory markers can ah sensitize the nerve endings and and play a role in that. and So it's definitely a, that we might call it a phenotype that specific researchers are are looking into because of that. And, you know, it's quite exciting at the moment. There's a lot of very effective weight loss strategies out there and they are getting good results and in terms of pain in osteoarthritis population. So it kind of just proves the point that there is a metabolic role in
00:26:08
Speaker
in osteoarthritis and that might be managed very well by weight loss. But I think we've got to be real careful when we do the weight loss that we do do the exercise as well. We don't want to lose muscle. We want to keep our muscles.
00:26:23
Speaker
Yeah, it's interesting that that because, you know, there would be an argument that if you lose weight from sort of a biomechanics perspective, you're you're going to reduce the load on, say, the knee and therefore that's what's helping the the pain. is it Would it just be that or is there...
00:26:40
Speaker
Would you say that there's something else going on that that's... Yeah, no, it's such... And it's a really good question I'd love to answer academically. I don't think we actually know the answer to that. So there's different types of study designs that you can do to answer that causal role of doing... So there is some stats out there by... I forget what they are to be honest, but you lose amount of weight and you reduce the load of your knee X and amount. But whether it's that amount that actually correlates to your improvement, I suspect that it accounts for a proportion of it. But the other part is through the other benefits of losing weight loss on your inflammatory system.
00:27:17
Speaker
And we don't know that relative to proportion. But it's a really good research question. Yeah, for sure. is Are there people looking at it at the moment?
00:27:29
Speaker
It's a hard question. You need certain data. um To be honest, that probably the only people that I could think that have the data for that are, it's in the US, Steve Mezier, he's got good data that I can answer that. And he has done correlation studies, but I don't think he did the causal analysis, and as far as best my memory is, and to tell you the proportion that would be mediat or improved by reduction in the loads across the joint. It corresponds to pain. Mm-hmm.
00:27:57
Speaker
Yeah, fascinating.
Sleep's Impact on Musculoskeletal Pain
00:27:59
Speaker
um tell us Tell me about sleep. What is it that um you've obviously gone down that pathway when it comes to research. For those that know me um and and Pain Coach, which is which is a ah clinical support tool that I've developed, it it looks at sleep as one of the factors that can contribute to pain. So um there's my biases on the table.
00:28:23
Speaker
yeah but but But why do you think sleep is so important and what role does it have in ah musculoskeletal pain? yeah I think it's um it's really interesting because sleep is one of those things that most of us can relate to and most of us can relate to feeling pretty ordinary after consecutive maybe number of nights per sleep even after one sleep right some of us have i can feel that. So in terms of where this comes into pain, we we know that people are more sensitive to pain the next day. So more, and you're more irritable, you're less likely to engage in your daily functions, you know, less likely to engage in your exercise. So it's this, again, response, when you don't sleep, you sort of build up, let's say, for the one about waste, and your brain doesn't wash it out overnight,
00:29:18
Speaker
and it builds up and this increases the in inflammatory markers in our body that again sensitize the nerve pave nerve endings. And this is how we think this is one role, how sleep can really impact musculoskeletal pain. But I think it's that's sort of it's really biopsychosocial as well, because you've got the social aspect where it's just kind of alluded to, where you you you kind of avoid. And we know that avoidance of doing things is is not good as well for our, we feel more stiff, it's not good for our function. And then
00:29:56
Speaker
you know, mental health is a massive component. I think that intersects between sleep and musculoskeletal pain. a Most people ah with with sleep problems will have, would say most, that's probably bit harsh, but a lot of people who maybe have had sleep problems for a long time will be mentally not as clear as they could be.
00:30:20
Speaker
im And there's about 20, 25% of people with osteoarthritis who would have mental health problems, like things that would struggle with anxiety or maybe depressive symptoms. So that further compounds that, that, but you don't have good sleep.
00:30:36
Speaker
and Yeah. It's interesting that, um, so you suggesting that it's not just that pain reduces the sleep because often people in pain they do struggle to sleep but that but that sleep itself actually may um directionally change pain yeah yeah yeah no and thanks for picking that up but exactly what you said most of us can relate to oh i've sore i just didn't sleep last night because was sore but actually the evidence is becoming very clear that poor sleep can
00:31:14
Speaker
make your symptoms worse over a longer a period of time. And this is maybe where I was getting at earlier. You want to kind of get ahead of this. So, you know, just being aware that your sleep is a huge predictor is it actually wild right now. There's data coming out left, right and center about how it's predicted to your mortality. You know, it will actually kill us earlier. Your mental wellbeing. It's not just musculoskeletal was a whole gamut of overall health and we've probably not taken sleep serious enough like we've you know at uni when we went through it was obviously exercise diet but i think more and more sleep has been recognized as that third pillar for overall health and being really protective of it and mindful of it and disciplined about it the same way as we you know if we can get into that groove around regular exercise that's the same kind of approach and consistency that we need around sleep as well you wrote a paper that i read just last night um i think it was an editorial or something like that but it's is sleep the new treatment for pain um tell us about that um
00:32:24
Speaker
paper and and yeah I'd love to know your answer as I'm sure most people will yeah a lot of that kind of stemmed from this observation that when we took trials so studies that had lots of people like trials or randomized controlled trials are kind of like our gold standard to say x causes and when you took those studies that had looked at people with chronic musculoskeletal conditions and you see the effects are They're not amazing, right? They're still what we call modest. We'd still love to see better effects. Of course we would. But they're the same as exercise.
00:33:03
Speaker
So if exercise is our first-line treatment for these musculoskeletal conditions, and the at least when we looked at these studies and we see that sleep does the same, maybe we start to manage our sleep better.
00:33:18
Speaker
and try to get people back on track and get people back on track with their sleep might actually help with their commitment to be able to do exercise. So I think that's sort of, it's maybe a little bit provocative that sleep could fix it. And I think this is, you know, what we kind of talked about already. it's's It depends and it's very multifactorial pain, that experience. But I do think that you know managing somebody's sleep will help them a long way and to manage their pain. The other thing about sleep is that when we don't sleep long enough, when maybe people are up early, you do actually consume more, you tend to eat more, so it affects your your body mass and your weight. is It's sort of this full loop circle. You're less likely to exercise because you're more fatigued.
00:34:02
Speaker
So it is all connected, if you like. and And one of the things I'd love to do right now is to actually look at that. If we started maybe with managing sleep before we look at exercise, because sleep,
00:34:16
Speaker
is quite nuanced in that the cognitive behavioral therapy for insomnia, it seems to work quote unquote for maybe 60% of people within eight weeks.
00:34:28
Speaker
And that is not a long time. Like eight weeks, if you could have fix your sleep in eight weeks, hey that's, that's pretty good, right? That's, that's, that's not a long time.
00:34:39
Speaker
and trying to give a power of people with the tools that, you know, if you go through a slippery slope, you can get back on, because you know what to do, what to manage it. And then sort of use that empowerment then to, to build on maybe exercise. And it may be bit controversial to say this, but maybe we try sleep to fix and sleep before we look at exercise. And that's what our trials are at the moment to see if we can get better effects when you do the two together.
00:35:04
Speaker
Yeah, that's awesome. Watch this space. I'm excited to to see the results that come. It's going to take us a while at the rate we're going, but we'll get there. Yeah.
Managing Sleep: Challenges and Strategies
00:35:14
Speaker
You know, um because I use Pain Coach myself with clients and and correlations come up. Okay, well, it seems that when you sleep poorly, your pain's worse or or things like that. But then the question often is like, which which of these things that we we can see is correlated to your pain?
00:35:32
Speaker
which of them do you feel like you have power over to control, to change? Yes. um Which is sometimes tricky when it comes to sleep. And I think there's probably people listening, thinking, yeah, look, I know my sleep's bad, but I don't know how to improve it. and And then the whole point of like that just stresses them out and then they're sleeping. Yeah, yeah, yeah. It probably exacerbates the thing. what Tell us, yeah, what is it about sleep is cbt for sleep um what are the like because i seems to many people don't know what the ins and outs of that treatment is can you can you take us through that like what should people do if they if they are struggling to sleep yeah so there are apps out there right so for cognitive behavioral therapy and just by way of disclosure i'm not a psychologist and this is where this treatment comes from this really psychology
00:36:26
Speaker
but People who there's sort of two main components that seems to be the most effective, if you like, when you talk to the psychologist. And we have this brilliant lady, Susan McCurry from Washington, helping us with this. And she's done this in lots of different populations, like cancer patients, patients with a kidney failure, like the whole gamut.
00:36:50
Speaker
So it's bed restriction is pretty powerful. So I'm not sure if maybe you've got some parents listening But being consistent with bedtime is a big thing, same as it is with a kid. and Going to bed at the same time when you are tired.
00:37:07
Speaker
And the whole thing is to really associate the bed with sleep right so you're not in there lying on your phone that's a big no-no so the bed is literally associated with sleep so while you're trying to get back on track you really want to a go to bed when you're tired so for some people that start off they might actually have their window bedtime windows shortened drastically so to make sure that they're so tired they're so ready for bed when they get to bed so it might be like 12 o'clock like some people i've seen some people and they might have to get up at six so It's really condensing that window that you're in bed is for sleep.
00:37:45
Speaker
And if you can't, it's so for some people who wake up in the night, whether it's for pain or, you know, sometimes we wake up thinking about things. And if you can't get back to sleep within that maybe 15 minutes, you get up and you go read something, you do something really kind of, not that reading is boring, but read something boring, something to like, just nearly bore yourself to want to go back to sleep again.
00:38:07
Speaker
and there's a lot of like sleep hygiene things as as well like making sure the room temperature is good making sure it's dark maybe have a hot shower before you go to bed so it says relax the muscles and those kinds of things can be really helpful if you if you're one of these folks who do struggle to get to sleep when you get there and so that's a bed restriction so bedtime fixing the bedtime being really consistent with that and ah that actually means as well over weekends so some of us kind of give ourselves a free pass at the weekends to socialize and obviously that's important but maybe during that period when you're trying to get back on track is sort of to to be consistent is is sort of the message there and then the other part is that sort of stimulus control so strategies when you can't sleep like
00:38:56
Speaker
It's maybe some people I, for myself, particularly, I think if I wake up in the night and I start thinking about all the things i have to do, I'm like, you know, I actually, if I can get up and I actually write them down, I used to put them on my phone, but was like, no, no more phone. So write them down. And I just like, okay, it's there. I'm not going to forget about it. And I try to go back to sleep, but having these simple techniques and it might be breathing for some people. you know, and I think that can seem quote unquote boring for some people, but the breathing technique seems to be very, very effective. ah When you, when you can't sleep, you're almost desperate to try anything. And that's one of the things that can be really effective for people. So just breathing in real slow, you know, almost like counting sheep.
00:39:38
Speaker
ah yeah So those are the sort of the two components that seem to be the most effective, but definitely the behavioral pit around bed restriction seems to be particularly potent but also maybe the one that's most challenging for people because you do get up and you're a smash like pretty tired the next day and you have to function and do your thing.
00:39:58
Speaker
Interesting when you say that because that's a surprise to me a little bit you know that yeah that the gold standard is try to get you seven to eight hours or whatever it may be and then you're saying actually in some individuals it's it's good to restrict that time for a period of time so that they actually, you know, they learn to associate the bed with sleep um and, you know, they so they sleep, I guess, deeper birth during that period. Right, and it's this kind of whole thing. It's when, and there is lots of data out there around sleep duration.
00:40:32
Speaker
And I think, you know, you touched on it earlier. that actually can cause a bit of anxiety for people. So they look at their watches now, it this you know, the watch tells us now you had good sleep or you had bad sleep, but but you only, you know, sometimes you feel good after maybe six, six and a half hours, but that's because you had good sleep. And when we sleep, our we have like different stages of sleep.
00:40:56
Speaker
And there's one phase of sleep the deep sleep in particular that researchers are going after because they feel like this deep sleep the longer you can do deep sleep which we might only need get an hour off at night a that if you can prolong the area of the time in deep sleep you'll have more recovery next day function it's it's better but if you're waking and up several times a night you disturb where you are in the stages so every time you have to go back to sleep you have to start back at stage one right? And a stage, the deep sleep is farther along in the stages you might never get there or your time in that stage.
00:41:33
Speaker
it's It's what was they call fragmented. And that's so sort of where you could feel a bit more rubbish. Like my bias to this is that if you can sleep well, if it's less than seven hours,
00:41:48
Speaker
I would, I think i would, for me personally, i would take that over trying to beat my head over trying to get seven to eight hours sleep. If I'm sleeping good and I got six hours, I'd run with it. And I felt, I felt good. I'd be like, yeah, I'll take that.
00:42:04
Speaker
Yeah. Interesting. Interesting. So one of the, one of the strategies that I, cause I got sleep interruptions are obviously important and,
00:42:15
Speaker
And it's because you kind of start that cycle again of sleep, right? You don't get go back straight into the deep sleep. You have to go through the stages again. yeah one ah One of the things that I ask, because I work in persistent pain, I work at a pain specialty clinic in Robina here. with It's a multidisciplinary team with pain specialists, et cetera.
00:42:36
Speaker
So often this is is something that that I look at. And one of the one of the things that I've found very useful to reduce interruptions because a lot of people, especially as they age, they get up more and more to go to the bathroom. Yes, yes. And so getting them to restrict their their water intake later in towards the night. So I usually say, you know, be well hydrated about three hours before you go to bed or four hours, something like that, and then don't touch any water um so that way they they pass um before they go to sleep and then there's if you know if we can just reduce one interruption that night the sleep quality just goes right up yeah um so i found that that's pretty pretty useful i don't know if that's part of the um cognitive behavioral therapy sleep hygiene stuff
00:43:28
Speaker
Yeah, I think it does fall into there, but it's probably underutilized, i think, out there. um It's such a great, and it's like it makes total sense and it just avoids that whole waking up and, you know, going back to zero again. And you're absolutely right. If you can have minimize at least one of those, you know, you're you're you're winning, right? You're in the definitely in the right direction.
00:43:52
Speaker
so So how many people, low percentage of people in the studies actually get improvement from this? Yeah. So from Sue's work, Sue's McCurry's in the US, she would say that 60, 65% of people would be like, and when we say get better, we actually you mean like almost recovered.
00:44:12
Speaker
So they would no longer have, they would no longer meet the definitions of having insomnia, which is pretty remarkable, to be honest, like that's pretty pretty good because even when we try to manage you know from your your clinical work when we try to manage pain it's almost getting it to a point where it's okay if people can live but it's ah it can be there it will be there and it it's sort of how you manage that expectation right so it does seem to be quite effective for a lot of people so one of the things that we will do in our work is try so we are doing like blood samples we're you know a ram at of things to see at the end of it can we predict who gets better responses so also you know cognizant that you don't want to waste people's time doing treatments that
00:45:02
Speaker
So it might not be for them. And that's totally fine. Like it's it's not for everyone. And you have to, think, be in the right space and headspace to do it and commit to do, especially that bed restriction, you know, and it's not for everyone. And being for first of all, we need to better understanding how these things work. And then we understand how they work better. We can target them better.
00:45:25
Speaker
But some of the the groups that we'll be particularly interested in in the studies are, you know, do you get do you are you going to get how to say this like more better you're going to get are you going to get a better response if you've got worse symptoms to start with are you the person and we're also going to have a look at sleep apnea so whether the coexistence of sleep apnea alongside insomnia actually matters for outcomes and it was really quite interesting we started these conversations about designing these studies and
00:46:01
Speaker
We, um sorry, we.
00:46:07
Speaker
it is this here? Is it? Come on in. just hello Hello, buddy. How are you? Can you say hi? Hi. Okay, but now let mommy talk. Okay, good boy. and When we have these, yeah, the sleep apnea, so when we started out, people were like, oh, you've got to take out people with sleep apnea. It's not going to work. It's not going to work.
00:46:30
Speaker
But then the more psychologists who we used, who we spoke to who had used CBT-I were like, no, the effects will be just as good.
00:46:40
Speaker
So we actually have not and excluded them from our studies. and And then we'll see at the end of it, if the results are the same. a I suspect that they're going to be, have more symptoms and problems when they start, like more severity of maybe difficulty with function, maybe mental health challenges. and But we'll see if we can nudge the needle for them as well.
00:47:07
Speaker
Fascinating. Yeah, that's really cool. And what is the primary outcome of this research? Is it sleep? Is it pain? is it what What is it that you're looking at? Yeah, really good question. So the trial that we have, a so we got two. One is with the US, so the department the military defense with the Department of Defense. and So the military folks are really interested in this because sleep is obviously a big thing for them. So in that trial, it's pain.
00:47:38
Speaker
And then in the one that we're doing in Australia alone, so we've got a trial that's funded across, we've got nine different hospitals on board at the moment. So we're trying to upscale the physios in the hospitals to deliver the cognitive behavioral therapy.
00:47:52
Speaker
And we're gonna have two two primary outcomes for that one, and it will be pain and so and sleep. yeah And the reason we've got the two primary outcomes for that trial is because we feel like we'll win Even if you just improve sleep and not necessarily pain, of course, we want to get our better improvement in pain.
00:48:10
Speaker
But sleep is such a massive part of people's life and it matters to patients. And so, yeah, we've got sleep included in that one too Yeah. Yeah. No, that's that's fascinating. It's how long before we're going to start seeing results on this? Yeah.
00:48:29
Speaker
Yeah, so we've started one, Sleep Fit, and it's recruitment from the community in Sydney and in Brisbane. And we've just got about five participants in. We just started three weeks ago, so we were very excited to get that off the ground. So we are recruitment.
00:48:46
Speaker
And then we've got the other one, which we're going through ethics. So hopefully we'll start recruiting by the end of the year. But honestly, it'll take us about four years at least get some answers, which is painfully slow. But that's the reality. Yeah. Yeah.
00:49:01
Speaker
Yeah. No, that is. That's why I asked the question. I'm like, is it going to be a five year horizon? Well, what are we looking at? Yeah. um How is it? in the In the study, how are you tracking sleep improvements? Are you using biometrics? Is it questionnaires? Such a good question. and we had a lot of argy-bargy about this because the watches, people get fixated, right? And you don't want to spike anxiety and stress. The long, what we went were for, we did do the watch, but we won't talk about it, which is because it's also measuring their phys activity and student behavior as well.
Innovative Research Methods: Technology in Sleep Studies
00:49:38
Speaker
And what we will do like a sub study within this trial is to look, see if we can predict pain flares using these behaviors, 24 hour behaviors and how maybe well they relate to the recovery of the flare. So that's kind of a side hustle.
00:49:55
Speaker
and oh But and yeah, sorry, what was the question? was walking around my high heels. This is funny.
00:50:08
Speaker
That's so good. That's hilarious. Sorry, Austin. No, no, it's good. I think we'll leave all this in there to be entertaining for the people listening.
00:50:19
Speaker
um and And it brings out the human side. We are not AI generated, Michelle. No, definitely not. Definitely not. We're the real authentic, you know, warts and all, kids and all.
00:50:32
Speaker
yeah Yeah. No, that's cold. I shouldn't call it warts and all that. That was harsh. No, no. I ah love kids. could be Yeah. The question was around whether you're going to use biometrics or what we're like questionnaires. So we were using this mattress. So we had actually gone with something called a sleep profiler. But to be honest, when we tested it with our consumers, it was just too involved, to be honest, to get them to do this by themselves. Now, David does use this in his low back pain work in queensland but we just felt like to give the people the support that they needed it was going to be quite challenging we've actually gone with a mattress withering's mattress i think it is so it's a sleep mat that you literally pop onto the mattress and you set and you forget it but it will get as close as you can without going to lab studies or to you know sleep labs to get at sleep apnea. And that's really like, it's very, it's going to be very discovery in the sense like there's so many metrics that these equipment can spit out on which one is more important clinically. We don't know yet, but we were particularly interested in getting something that could capture the sleep apnea.
00:51:44
Speaker
Yeah. Yeah. Because some of the other, When you go to these labs to get a formal diagnosis of apnea, it's really only over one, two nights. And a lot of the criticisms is that's not representative. So having something that can measure continuously for us over the duration of the one year that people are in the study will be, it's going to be very, very interesting.
00:52:07
Speaker
What's your hypothesis? What do you think is going to happen? Look, I have to be positive with this. I think that when we manage sleep on top of exercise, it will do better than when we just do exercise or physio usual physio care. So one trial looks at aerobic exercise, the other trial is usual physio care in the hospitals.
00:52:27
Speaker
um And I'm going to be optimistic and say that we will improve pain more so on average. And even if we don't do it on average, there will certainly be people who will get a better response.
00:52:40
Speaker
And hopefully we've got enough granular data to do some really innovative work to find out who they are and why that happened so we could set hospital systems physios up better to to know who to go okay i think you'd respond pretty well to this because of x y and z fascinating yeah and do you think this will translate to other areas of of musculoskeletal pain I do. I think I think it's definitely got the legs for it. And it's something that, you know, we've talked about with shoulder pain, neck pain, and You just need to modify things of course to, to the side, but because the principles of how sleep and pain interact, it's not really site dependent, right?
00:53:27
Speaker
It's, it's the pathophysiology of them. So definitely I think the scope to broaden it out to not just knees and hips and back. And we're quite excited from a nerdy point of view.
Future Implications and Encouragement for Lifestyle Change
00:53:41
Speaker
um that the trial that we've worked in in Australia across the hospitals, that we've set it up as a basket study design. And what that essentially means is that we should be able to answer the question for people with hip pain, people with knee pain and people with back pain. Because traditionally we put them all together you actually need massive numbers of paid participants to really disentangle whether the effect was different depending on your side of pain. But we've,
00:54:10
Speaker
I don't know, borrowed, plagiarized is the right way, but if we've taken this approach from cancer, rare cancers. And there's a lady who's working with us from the UK in Bath. And yeah, they do these basket designs in rare cancers to answer the questions for specific types of cancers. So this is the approach that we've taken here. And hopefully the idea is that you're more efficient,
00:54:37
Speaker
ah you can get an answer, quit even though it is going to be four or five years, but you'll have an answer for three different types of the most chronic conditions. Yeah, that's huge. it's it's really exciting stuff. ah I think it should translate into good clinical practice and and outcomes for people with pain, which is what's so exciting. I i kind of get frustrated sometimes with some research because it's so... um esoteric and like it's not actually gonna help the patients in front of me sometimes or at least it feels that way yeah maybe it will maybe it's a ah launching pad but this one seems very practical so yeah I'm excited to to see what the outcome is no thanks Lachlan and yeah we are too we just have to stick with the
00:55:24
Speaker
And stick with the processes. Yeah, yeah. Yeah, if you um if you were speaking to someone that had crappy sleep and and chronic pain, what would your advice be to them?
00:55:39
Speaker
I would go and talk to the GP about getting some referrals. you You know, you can try the online, the apps. There's Sleepio. I'm going to forget them. But there there are some apps that you could try maybe before you go to the GP. I'm saying not to go the GP for drugs. try Try your behavior change stuff first because that's the stuff that outlasts the pills, right? we' I think very few people really want to take pills or even remember we don't take them even when we are prescribed them.
00:56:09
Speaker
because this is something that really getting on top of your sleep can empower you and it spills into other aspects of your life, not just pain. But I think you can go in with the expectation, hey, if I manage my sleep, let me just see what it does to my pain experience and can I get on top of it a little bit more? And know that every night is not going to be perfect. Every night is you know, same way every day we show up. It's, it's, it's, it's not perfect, but just doing, be consistent with doing the best that you can and setting yourself up as best you can and just accepting that. it Okay. It didn't go right. That's okay. Let's move on. And remember that, you know, when you are in those moments or those periods of flares or in it, it's particularly
00:56:53
Speaker
bothersome and and sore and debilitating that those moments will pass, you know, those days will pass. And when you get to the other side of it it's, it it will come right there. There will be, you will be okay. And think that's your another opportunity to to sort of get on top of these everyday things that we can do. Cause it's not going to be a one magic pill or bullet that it's, I think about consistently showing up, making good choices as we can,
00:57:23
Speaker
in terms of our health across our sleep, our movement, or our diet, that over time helps us overall. Yeah, i I say this often. I i believe strongly that you're one habit change from lasting pain relief.
00:57:38
Speaker
And i i really I really, truly believe that. And I think the research is starting to, you know, bolster that, the strength of that statement. But it's such a cool thing that we can not just get short-term relief, but we could actually change the the long-term trajectory of these diseases and and pain that's associated with them. It's exciting.
00:58:01
Speaker
Yeah, no, 100%. I love that. So you're one habit away from long-term pain relief. I'm going to think on that today. Awesome. um If people want to learn more about you, stay up to date with the the research that you're doing, where where should they go to find you?
00:58:20
Speaker
Yeah. and So we have a LinkedIn page that people are very welcome to engage
Conclusion and Contact Information
00:58:26
Speaker
with. It's the musculoskeletal research hub. So outside of the University of Sydney. So that's where we post most of the the work that we do. And yeah, you feel free to a email me, you know, these profiles and whatnot on University Sydney websites, but very happy to be contacted. Yeah.
00:58:46
Speaker
yeah Awesome. Awesome. Well, thank you so much for your time. um You're obviously a busy young mum with, you know, lots going on, lots of moving parts. Thanks for getting your son to pop his head in at some stage.
00:59:01
Speaker
ah No, all good. Thank you so much. No, thanks so much, Lachlan. I really enjoyed it. And thanks for making it so easy to like to chat. And yeah, hopefully people find it helpful.
00:59:15
Speaker
For sure, they will. Appreciate it. ah All right. Take care.