How important is sleep in helping to avoid surgery?

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

How important is sleep for helping to avoid surgery?

Often a patient will come into one of our clinics and present themselves as not only a person suffering from chronic pain, but one that suffers from chronic insomnia. The connection is obvious, many of our patients’ insomnia issues are due to pain. Get rid of the pain and sleep is improved. Improve sleep, improve the body’s ability to heal.

As simple as that sounds inadequate or poor sleep is often an overlooked factor in health and healing.

A well-cited 2004 study from the Johns Hopkins University School of Medicine, published in the journal Sleep Medicine Reviews (1), makes for a simple understanding of a very complex subject:

  • “Sleep disturbance is perhaps one of the most prevalent complaints of patients with chronically painful conditions. Experimental studies of healthy subjects and cross-sectional research in clinical populations suggest the possibility that the relationship between sleep disturbance and pain might be reciprocal, such that pain disturbs sleep continuity/quality and poor sleep further exacerbates pain.”

A November 2022 paper in the journal Frontiers in physiology continued this line of research by suggesting “Insomnia is very common among people with chronic pain, and is often thought to be a consequence of chronic pain, but the findings demonstrate a bidirectional relationship with pain (insomnia can make pain worse, pain can make insomnia worse).” The researchers noted that “there is a close mutual effect between sleep disorders and central sensitization in people with chronic pain.” Further insomnia can induce general hyperalgesia (greater sensitivity to pain) and anxiety state in healthy people, in fact, the “higher levels of sleep disturbance corresponded to greater anxiety symptoms” and disrupted circadian rhythms may be responsible for the increased risk of mood disorders.”

Clearly, sleep impacts pain, pain impacts sleep.

We usually do not have to take much time convincing patients that our treatments will be more effective if they work on strengthening their immune system and push themselves towards a more healthy lifestyle. Active, generally healthy people, heal very well.

But it is hard for people in chronic pain to get themselves to a point of healthy well being if they can’t sleep: These are the things we hear all the time:

  • I am fine all day long, the minute I lay down, my knee starts hurting. It wakes me up a lot.
  • I am okay sometimes if I take extra strength Tylenol or Motrin or Advil before I go to sleep
  • My doctors say “knee pain at night,” is the number 1 reason for knee replacement.

The best recommendation we can offer is to get better sleep, get rid of your pain.

In our clinics, we may make general recommendations for what you can do to help your sleep. But we do emphasize that sleep is a component of healing, not THE component of healing and the best recommendation we can offer is to get better sleep, get rid of your pain.

For example: How important is sleep for preventing back surgery?

Now let’s look at some research. Here we have some studies that suggest that if you can get to sleep you may be able to prevent back surgery.

  • In our clinics, we will avoid using sedation and sleep medications as the primary source of pain management. What we will focus on is eliminating or reducing your pain with regenerative medicine injections such as Prolotherapy which we will explain and show documented evidence for below. Prolotherapy strengthens and restores joint and spinal instability in many patients. Reduce instability and pain, the patient sleeps better.

Writing in the American Journal of Preventive Medicine,(2) doctors at the U.S. Army Research Institute of Environmental Medicine studied risk factors for low back pain and spine surgery. One of the risk factors is sleep deprivation which the doctors found was associated with increased risk of back pain becoming chronic/recurrent and causing the patient a faster time to surgery.

Poor sleep quality among people with chronic low back pain appears to be related to worse pain, poor physical function, and pain catastrophizing.

  • Poorer sleep quality was significantly related to higher pain ratings,
  • poorer physical function,
  • and higher pain catastrophizing.

Doctors at Rush University Medical Center did a further analysis which they published in the Annals of Behavioral Medicine. (3This analysis, averaged across the day, revealed that:

  • Poorer prior night sleep quality significantly predicted
    • greater next day patient ratings of pain,
    • poorer physical function
    • higher pain catastrophizing
    • and negative mood and low function uniformly across the day,
  • Good sleepers reported relatively good mornings, but showed pain, affect and function levels comparable to poor sleepers by the end of the day.
    • (It is interesting to note that the good sleepers start the day off well but as the day wore on, the pain caused similar issues of physical function pain catastrophizing.  This should clearly show that sleep is an important part of a comprehensive program to reversing back pain BUT not THE component of healing).

Doctors at the University of Sydney (4) in Australia are conducting studies to connect low back pain and poor sleep. In published research they wrote:

  • Poor sleep quality is highly prevalent in patients with low back pain and is associated with high levels of pain, psychological distress, and physical disability. Studies have reported the relationship between sleep problems and the intensity of low back pain. Accordingly, effective management of low back pain should address sleep quality.

Clearly, we can produce studies that will show how poor sleep negatively affects patients with knee, hip, shoulder, neck, and all joints. But the point is clear, sleep and chronic joint pain are connected.

Pain and insomnia

Doctors at the Norwegian University of Science and Technology wrote in the Journal of Sleep Research (5that chronic musculoskeletal pain increases the risk of insomnia, particularly among those who report several pain sites. Although there was no clear evidence of modifying effects, these results suggest that a healthy active lifestyle (weight loss and exercise) reduces the risk of insomnia in people with chronic musculoskeletal pain.

Doctors in Spain investigated whether sleep quality is associated with improvement in pain and disability. In their study published in The Clinical Journal of Pain, of 422 patients with neck pain  the doctors were able to conclude: “neck pain is less likely to improve in patients with poorer sleep quality, irrespective of age, sex, catastrophizing, depression, or treatments prescribed for neck pain.”(6)

  • In other words, their suggestion was to address sleep problems to improve neck pain.

In our opinion, the permanent cure for neck pain and instability is not long-term narcotic medications or steroids, though sometimes a prescription or nerve block is necessary to get a person through the most acute phase of pain. Decreasing the acute pain allows the patient to sleep and rest while the Prolotherapy stimulates the ligaments to tighten and properly restore vertebral alignment.

Prolotherapy research – pain reduction – sleep improvement

When patients come into our clinics and they ask, “what can I do to help me sleep at night?” The answer, as we stated above, is “get rid of your pain.” If we can get rid of the pain, the patient will not need to take extra or super strength pain pills before bedtime. If we can jump-start the healing process for them, start reducing their pain, the patients find that they can sleep better and that better sleep in helping them heal.

This is how Prolotherapy treatments can positively impact chronic pain:

In the Journal of Prolotherapy, our Caring Medical research team reported on sleep and knee pain:

Prolotherapy helps decrease pain and improve the quality of life of patients with unresolved knee pain. Decreases in pain, stiffness, and crunching levels reached statistical significance with Prolotherapy. The percentage of patients with less knee pain was 95%, and 99% reported long term improvements in stiffness after Prolotherapy. Eighty-six percent of patients decreased their need for additional pain therapies, including medication usage by 90% or more, after Prolotherapy.

  • Eighty-two percent showed an improvement in sleep.
  • Seventy-four percent of patients had trouble sleeping prior to Prolotherapy with 82% saying they could sleep much better after Prolotherapy.
  • Ninety-two percent stated that the improvement in sleep has at least mostly continued after Prolotherapy (50% or greater).(7)

In the Journal of Prolotherapy, our Caring Medical research team reported on sleep and foot and toe pain

  • In regard to sleep, 53% of patients felt their foot/toe pain interrupted their sleep.
  • After Prolotherapy, 90% of this group had improvements in their sleeping ability.8

In the Journal of Prolotherapy, our Caring Medical research team reported on sleep and shoulder pain

  • In regard to sleep, 80% of patients said that their shoulder pain affected their ability to sleep before Prolotherapy.
  • After Prolotherapy, 88% could sleep much better.9

In July 2018, researchers publishing in the medical journal Scientifica (10), that in test subjects with shoulder pain, Prolotherapy injections significantly improved patients’ range of abduction and improves sleep within 12 weeks of treatment compared to conventional physiotherapy management.


Chronic pain patients are often prescribed antidepressant medications, like Elavil, to aid sleep. These medicines provide some temporary pain relief and aid sleep. However, chronic pain is not due to an Elavil or other pharmaceutical drug deficiency. Chronic pain has a cause. Until the etiology is determined and treated, all therapeutic modalities will provide only temporary relief. Chronic pain and chronic insomnia go hand in hand. The adrenal gland secretion of the hormone cortisol normally decreases at night, and the pineal gland secretion of melatonin increases, thereby enabling sleep. Unfortunately, the chronic pain patient’s secretion of cortisol does not decline because chronic pain is seen by the body as stress, thereby stimulating the adrenal gland, which reacts to stress, to produce cortisol. This results in chronic insomnia. The secretion of cortisol will stop only when the chronic pain is relieved. Chronic insomnia increases chronic pain. Prolotherapy breaks this cycle. Pain relief leads to a good night’s sleep.

Sleep is vital to health maintenance. Sleep stimulates the anterior pituitary to produce Growth Hormone. Growth Hormone is one of the main anabolic, meaning to grow or repair, hormones in the body whose job is to repair the damage done to the body during the day. Every day, soft tissues including ligaments and tendons are damaged. It is vital to obtain deep stages of sleep, as during this time Growth Hormone is secreted.

Without deep stages of sleep, inadequate Growth Hormone is secreted and soft tissue healing is inadequate. Growth Hormone levels also appear to be increased with exercise and amino acid supplementation with ornithine, arginine, or glutamine.

A natural way to increase sleep and improve deep sleep is aerobic exercise, like cycling, walking, or running. Melatonin, L-tryptophan (an amino acid), valerian root, and gamma hydroxybutyrate are also beneficial natural sleep aids.

If you have questions about sleep problems and chronic joint pain, get help and information from Caring Medical


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