Case Study Excerpt: Creating a Sleep Protocol for Patients with Chronic Pain

Sandra is a 43-year-old living with her husband and two school-age children in a New England suburban neighborhood. She is an executive at a large financial company in the city, working long hours sitting at a desk and traveling internationally to Europe at least once a month. In the last year and a half, she developed low back pain that has been increasing in both frequency and pain level and has been to her primary care physician multiple times complaining of pain and discomfort.

Practitioner Perspective: Catherine Darley, ND

Catherine Darley, ND is the founder of The Institute of Naturopathic Sleep Medicine in Seattle, Washington. The Institute’s mission is to provide patient care and public education about sleep health, and research on natural treatments for sleep disorders. Darley writes reviews of sleep health topics regularly for professional naturopathic journals.

First Visit

During Sandra’s first visit, Darley focuses on ruling out organic disorders that could be disrupting her sleep, such as sleep movement disorder or sleep breathing disorder. In the clinical interview, Darley asks Sandra several questions about her sleep and family history.

Darley talks with Sandra about what she thinks is the best amount of sleep for her. Often patients think about the number of hours they need to get by, but Darley wants to know how much sleep Sandra needs to feel energetic, in a positive mood, cognitively sharp, able to relate well with others, and overall feel in a state of optimal health. She also asks Sandra to consider what she would prefer: a long, sleepdeprived day where she’s having increased pain versus a shorter day where she’s getting adequate sleep and feeling better. From there, Darley can coach Sandra to create a lifestyle centered on healthy choices.

The foundations of Sandra’s health have deteriorated, so the start of her treatment plan is reestablishing her foundations of health. Darley recommends Sandra get back on some sort of exercise plan and an anti-inflammatory diet. In addition, she wants to address Sandra’s social connections. A growing body of research shows that loneliness disrupts sleep. Her sleep is worsening as the pain worsens, but as she’s also starting to feel isolated, that can worsen sleep as well.

Darley also discusses Sandra’s alcohol consumption. Even a small amount may help a person fall asleep, Darley said, but as its metabolized can cause a person to experience sleeplessness in the middle of the night. She asks Sandra to consider a week to 10 days of complete abstinence to see if it helps with her sleep symptoms.

Finally, Darley discusses the importance of having her family on board to support healthy lifestyle habits at home.

Care Plan

At the end of the first visit, Darley works with Sandra to create a daily schedule for optimal sleep, based on what she says is the ideal amount of sleep for her, which includes:

• A wind-down time in low light starting an hour or so before bed 
• A lights-out time 
• A wake-up time 
• A bright light time for 20 minutes after waking up

Darley recommends setting an alarm for wind-down time an hour before bed, at which point Sandra, her husband, and her kids will turn off electronics, turn down the lights, get in comfortable clothes, read a book, listen to relaxing music, and overall mentally prepare for sleep.

Darley finds that Sandra is resting in bed in dim conditions after work, which could further break down her sleep. She suggests Sandra rest in a room other than her bedroom with good light exposure. She also wants Sandra to keep track of how often she is resting to see how it is influencing her pain and sleep.

Pain and sleep have a bidirectional relationship, so Darley must work with Sandra to improve her pain and her sleep at the same time. In addition to lifestyle improvements, Darley recommends supplements to help deepen sleep, starting with glycine, which decreases body temperature and, as temperature decreases, it can improve deep sleep.

Darley understands Sandra has been apprehensive about seeking help for pain in the past, so Darley makes a point to show the research and evidence base of the approaches she suggests. She also asks her to have realistic expectations on how long it takes to improve sleep and decrease pain, framing her care plan as a four- to six-week trial period. Darley emphasizes that Sandra has been in pain for over a year, and any problem lasting that long deserves at least a couple months of attention.

Long-Term

Once Sandra is sleeping better at home and in less pain, Darley will address the international travel and help her develop strategies for coping with the time difference. This may include shifting her body clock an hour a day before her trip or negotiating different work hours while she’s on the trip, to effectively decrease the hours of time change. Anything beyond a two-hour time difference is a challenge to the body, so Darley wants to have a conversation about how to best shift her lifestyle at home so she can minimize the circadian adjustment she has to make each month.

Editor’s Note: This is an excerpt from the e-book, The Integrative Healthcare Team: A Pain Management Case Study. To access the full text, click here.