Systematic Approach to Sleep

posted in: Stage 1, Stage 1: Step 4


  • Adequate sleep is a necessary requirement for healing.
  • Insomnia is a cause of chronic pain, and it is not the other way around.
  • It is almost always possible to experience a consistently good night’s sleep using a combination of approaches.
  • Do not undergo any major invasive interventions until you have solved this issue.


Insufficient sleep is a major factor that compromises one’s coping capacity and increases pain. It is consistently solvable with a stepwise approach regardless of the level of your pain. The outcomes of the various treatments are easily assessed. The key is focus and persistence. It is a myth that you need less sleep as an adult and at least seven hours of sleep is the desired amount. Few patients suffering from chronic pain are getting adequate sleep.

Incorporating sleep into the treatment of pain was my first step in conceiving the DOC protocol. I felt I had a whole new weapon that was effective and yet simple. There was always some improvement in their sense of well-being if not also their pain.


 Sleep and pain

I had originally thought that people in chronic pain could not sleep because of their pain. But a large study out of Israel showed that it is lack of sleep that induces chronic low back pain. It also demonstrated that the reverse was not true – that pain caused insomnia.1

Another study documented that lack of sleep was a bigger predictor of becoming disabled than the severity of back pain. Even more interesting to me was that this was also true for leg pain (sciatica), which surgeons generally feel is the most disabling problem.2

Successfully addressing insomnia is the highest priority. The DOC Journey will be marginally effective if you aren’t getting 7 or 8 hours of restful sleep. Not sleeping is NOT an option. No major decisions regarding your spine care should be made until you feel rested during the day. This is particularly true regarding spine surgery.

I had one businessman that had experienced chronic neck pain for almost two years. There was no specific injury. He continued to work as an owner of a small accounting firm but was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to sleep a full night. I saw him back at two weeks to check on how the medication was working. I was planning on starting aggressive physical therapy six weeks later. When he came back for his eight-week visit, I was surprised to find he was pain-free after being in pain for over two years.


Start sleeping – NOW

There are many ways to get a good night’s sleep. Most people can figure out a solution using a combination of the self-directed suggestions below. If you are still struggling after a few weeks, you should discuss it with your primary care physician. The details of each of these suggestions are outlined in the next lesson, which is the sleep chapter of my book, Back in Control. Please use this a reference to devise your own approach.

Approaches to Insomnia – self-directed

  1. Sleep hygiene – well-known set of principles to optimize sleep.
  2. Stress management at bedtime – i.e., don’t read business emails while you are trying to fall asleep.
  3. Exercise – It is not helpful to exercise late in the evening, but overall physical conditioning improves sleep.
  4. Expressive writing – has been shown to help decrease the time it takes to fall asleep.
  5. CBT-I – stands for Cognitive Behavioral Therapy Insomnia. There are online resources that may be helpful in addressing some of the anxiety around trying to get a good night’s sleep.
  6. Over the counter sleep aids – I do not have specific recommendations and they should not be used long-term. You also should make your physicians aware that you are using them.

Under the guidance of a physician

  1. Prescription Medications – There are many medications that are effective in dealing with insomnia. I have observed that if you are suffering from chronic pain that you often need a kick-start with strong sleep meds. Once your nervous system quiets down you can and should come from them relatively soon. Using narcotics for sleep is not recommended and creates many additional problems.
  2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. In sleep apnea your airway intermittently becomes occluded while sleeping and you are gasping for air. Sleep quality is poor, and you are tired the next day. More importantly it has an adverse effect on your heart. If simple measures are not working, it is important to diagnose and treat this. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.


A consistently restful night’s sleep is necessary for healing from chronic mental or physical pain. Insomnia causes chronic LBP and must be addressed as the first step of healing. It is generally solvable regardless of the level of your pain. Most people can improve their sleep with simple self-directed interventions, but you should not hesitate to seek help from your physician.

Use the sleep chapter from my book, Back in Control, as a reference. Read it carefully and implement the steps that are doable for you. As you layer on additional strategies, you will find a way to sleep.


  1. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
  2. Zarrabian MM, et al. “Relationship between sleep, pain, and disability in patients with spinal pathology.” Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.