Recover Deep Sleep With Mind-Body Therapies For Pain Relief

Anna Esparham, MD

Hi. So happy to be here, everyone. Thanks for having me. I got into all of these integrative therapies because I actually got sick myself back in medical school and residency. And funny enough, one of the chronic illnesses I had associated with chronic disease, chronic pain, and autoimmune disease was insomnia. So I actually had to go through a lot of these therapies myself to actually be treated for my own insomnia, right as I got done with residency. And so that’s what led me to go get extra training in integrative medicine and medical acupuncture and all of the therapies that are adjunctive used for many chronic conditions, including pain and sleep issues. And so, yeah, it was just a personal story to help myself and then eventually help my patients as well.

Audrey Wells, MD

You know, I absolutely love that. And like you, I’ve had issues with insomnia and I kind of walked a mile in the shoes of people that I see and treat. Wouldn’t you agree? It just makes the work so much more meaningful.

Anna Esparham, MD

Yeah. And you know, some days I am just like, please, can I just not have to experience this in order to take care of my patients? But it just, it allows my patients to get that much better because I know a whole lot more, because I’ve researched, I’ve experienced it. I’ve been to many of the specialists, I’ve done it myself, and I feel like my patients are getting so much better than they otherwise would in just a conventional, traditional standard of care practice.

Audrey Wells, MD

Absolutely. And it’s I think it’s a privilege to kind of hold space for the idea that even somebody who has so much expert expertise and experience like you do, even for a sleep doctor like me, I still go through periods of insomnia. And that speaks to what a human condition it is and really helps to sort of fuel compassion and really get your heart in the right place to help people who are struggling.

Anna Esparham, MD

Yeah, and I totally know what it’s like when you can’t sleep and you’re so fatigued and you’re trying to work or trying to go to school. And it’s just there’s so much emotional issues going on, mood issues, cognitive issues, and you’re just really struggling. And for anyone who has a chronic illness, along with that insomnia, it just makes it that much worse.

Audrey Wells, MD

I totally agree. And I want to sort of dive into the idea of people who struggle with chronic pain and how that interacts and plays with sleep and sleep quality. Tell me what you’ve seen.

Anna Esparham, MD

Yeah. So I actually did quite a bit on sleep association with pain just because I do a lot with adolescents who are also well known to both have a lot of headaches and certain chronic pain conditions. And then also a delayed phase sleep disorder or another type of sleep issue in addition to insomnia, just because of the neurodevelopment that’s going on with adolescents. And so I kind of delved deep into this when I worked with the sleep lab. So I had my colleagues were sleep physicians, and sleep techs because I actually worked with them in their own lab while I took care of the headache and the pain patients during the day. And what’s interesting is that sleep deep is actually a little bit more of a powerful association that actually increases the risk for chronic pain later on in kids. And then, of course, eventually adults by the time they reach adulthood. So what happens is a couple of years before kids develop pain, whether it be headaches, amplified pain, or complex regional pain syndrome, those are just a couple of the chronic pain issues that kids can have. 

They actually have been found to have sleep disorders before two to three years before they develop chronic pain. And so the association is a little bit stronger that you have sleep issues first and then you develop pain. And so even though it’s bidirectional, meaning that if you have pain, you can have sleep issues and that if you have sleep issues, you can also worsen your pain. And so there is that bidirectional component. But sleep is more important in that we can actually prevent we can potentially prevent chronic pain by getting enough quality, deep, and refreshing sleep earlier on. The one thing that is also associated with chronic pain is that even if you change your sleep routine by an hour, you can actually have worse pain. If you already have some kind of pain syndrome, especially in adolescence. So just that one hour, like you will, these teens who are staying up late at night on the weekends, for example, then they can have worse pain on Monday and Tuesday when they go back to school. And so we try and get them on that sleep routine so they don’t change it too much, so they don’t worsen their pain syndrome.

Audrey Wells, MD

Yes, I know that as social jetlag. So you’re kind of giving yourself the effect of traveling across time zones. And normally you associate that with some degree of adaptation to the place that you’re going. But when you do it in a social way to, you know, sleep in on the weekends, then you end up having the same effects when it comes Monday morning and you’re trying to get up and do your social or school obligations, your work obligations. That’s social jetlag.

Anna Esparham, MD

Exactly.

Audrey Wells, MD

Yeah. I think people underestimate the degree with which sleep can affect something like pain or chronic pain. Is this something that you see in your work with adults as well?

Anna Esparham, MD

Yes. So I also see now, I see a lot more chronic pain in adults because I’m getting training and osteopathic neuromusculoskeletal medicine. And that is a modality that doctors can also get board certified and mostly treating chronic pain syndromes, whether it be low back pain, sacroiliac joint pain, hip pain, osteoarthritis, related pain, and so on and so forth. And so what I’m seeing in the clinic, too, is insomnia associated with their chronic pain syndrome. And even though our osteopathic manipulative medicine and treatment that we do, while it can take care of the pain acutely for several weeks, they also have to do quite a bit of work on their own in terms of self-care, whether it be sleep routine, adding mind-body therapies which we can get into, and then also either seeking a therapist or going to counseling. If there is an underlying root issue of anxiety and stress that is causing also their pain to be worse and their sleep to be worse.

Audrey Wells, MD

Yeah, anxiety, stress and even mood disorders like depression often go hand-in-hand with sleep difficulties getting to sleep or staying asleep. And in my work as a sleep medicine physician, I always impressed with the burden that people with chronic pain carry. It really can wear you out. It sort of sucks your energy. And a common symptom that people with chronic pain describe is tiredness. So it’s sleepiness and tiredness and it gets all wrapped up in a bit of a complicated ball. I wonder when you are sort of trying to manage a person who has sleep problems and chronic pain, where do you start? How is your approach?

Anna Esparham, MD

Yeah, so I always start out with their goals and how willing are they to meet those goals because it is a lot of work to take care of chronic pain. I would say I always talk to my patients that it’s 20% of our job as physicians to help them in their journey to heal from chronic pain and 80% of the work is what they do to take care of their pain. And so they really have to be on board and they have to be motivated and understand what they need to do in order to take care of their chronic pain. And a lot of that is the mind-body therapies. And so there are just pain programs out there that focus just on mind-body therapies, no pharmacologic care, and no other procedural care. So that includes like injections, for example. So pain injections. So just focusing on mind-body therapies which include meditation, and hypnosis, we also include emotional freedom, technique or tapping, which we’ll talk about, aroma therapy, and so on and so forth. The one thing is that a lot of people who have chronic pain and insomnia they just want something quick to take and to cure their illness right away and there is no such thing. So most of the studies actually point to mind-body therapies being one of the top treatments for chronic pain. It’s just hard to do because if someone has chronic pain, insomnia, anxiety, and depression, it is so difficult to get into a mindful, meditative, and peaceful state, which is often what the mind-body therapies recommend in order to achieve healing on their journey to end chronic pain and insomnia. So I usually start with where they’re at. 

Tapping is one of the easiest ways that I have found in my patients to relax, to release anxiety, to release stress, and to calm down before they can get into either a hypnotic state or a meditative state. And so tapping has actually been studied in about over 100 and I believe, 16 studies. That probably was a couple of years ago. So probably more now and I really got into this for a lot of reasons why I got into this was because people could get into meditation or hypnosis on their own because it was too difficult for them. They couldn’t sit still, they couldn’t shut off their mind. And so tapping is just a form of a combination of acupressure. So you’re tapping on different acupoints while you’re affirming different goals in your life. Say you want to get rid of chronic pain, you want to be able to sleep better. You just be you’re able to tap on these points while you’re just thinking about those goals of yours, and that somehow decreases your cortisol level, gets you into a relaxed state, and improves your heart rate variability, which is a calm, relaxed, restful state, and helps them realize that they can get into a relaxed state before they start getting into a meditative state. So usually that’s where I like to start, and that’s a little bit more successful than just pushing meditation down everyone’s throats when they’re not quite ready.

Audrey Wells, MD

Totally. I’ve had that experience too, where, you know, it’s very uncomfortable to be in pain and sleep deprived. And so people really want to escape that. And to your point about the medicine and the injections, those seem very easy and easy to wrap your head around. But techniques like the emotional freedom technique, which is also called tapping and breathwork, are things that you can do in the moment. So I love that you brought that up because you can literally start that and achieve some benefit right then and there. That helps you to take another step in the right direction. I wonder if you can elaborate a little bit on sort of the success rates or the benefits of tapping, maybe even as compared to other pain anti-pain modalities? And just describe for somebody who may be a bit skeptical on what the power of tapping can do for you.

Anna Esparham, MD

Yeah. So tapping, they’ve actually done, I believe, a recent systematic review. So that means these researchers combined all the research studies and all the randomized controlled trials. Then what they have found was that the emotional freedom technique was effective for many psychological conditions and physiologic conditions related not only to anxiety, depression, PTSD, or certain phobias but also pain, insomnia, and autoimmune conditions. And then also for those who are very healthy and who are high performing, they studied the tapping for sports performance and showed improvements. They also studied hypnosis for that as well. And then also biological markers of stress, which mostly decrease cortisol. So when we get stressed, we have higher chronic cortisol elevations that can also cause a lot of aging and induce more symptoms of chronic illness and then also decrease or increase that heart rate variability, which is our parasympathetic rest, relax place state versus that sympathetic state, which is our stress and our fight or flight state. So it’s really trying to improve that relaxation.

Audrey Wells, MD

So true. And I think the term emotional freedom technique is really apt here because it sort of liberates a person from the emotions that can be associated with sleep deprivation and chronic pain. Dr. Esparham, I wonder if you can give us a mini-lesson about tapping if somebody wants to get started with this, even as they’re watching this video?

Anna Esparham, MD

Yeah. So first you want to have a goal in mind before you want to start your tapping session. So in this case, if we want to talk about sleeping better, we can just go ahead and use a goal for everyone today as sleeping better, waking up, feeling refreshed, and then being able to fall asleep easily. So the first step is tapping on the karate chop point and the karate chop point is just on the edge of the palm. So on the lateral side all you have to do and you don’t have to use all your fingers. I tap with all three fingers on this karate chop point. Yep. It’s just where you karate chop that board for example. That’s why they call it the karate chop. And you can use either hand, you can switch hands. But what you want to do is you want to state your goal and that you basically say you can say it in your mind or you can say it out loud. I really am having trouble with falling asleep and staying asleep and I really want to hear that today. I really want to heal my sleeping issue because I’ve just been dealing with this too long and I’m so fatigued. So and that’s all you have to do. And the karate chop point, that’s the only time you need to use that karate chop point. There are different variations, but then you want to start with the eyebrow points and then it’s just at the middle part where sort of that nose bridge reaches those eyebrows and you can tap some people if they can’t use both hands, they can use one hand and that’s totally fine. And then you just continue affirming that you can’t sleep and that you want to be able to heal that sleeping issue. Then you go to the sides of the eyes and tap there, continually affirming that you’re ready to heal your sleep, and then under the eyes and then under the nose and then under the mouth, all ready continually in your mind, stating that you’re having difficulty sleep and you’re ready for that to change. And then the next one is underneath the collarbone.

Audrey Wells, MD

Sort of underneath the bone itself.

Anna Esparham, MD

Yep. And there’s a little space and usually it’s either ticklish or pretty sore for most people who have pain or who have insomnia or chronic conditions. And so you’re tapping under there while you’re still affirming that you really need help with wanting to get to sleep and then right underneath the armpit. So in that axillary line that armpit line just across from the chest and that you’ll tap there either side, it doesn’t have to be both. So it doesn’t really matter. And then the very last one is on top of the head. That is the first go-through when you’re affirming that you truly want to help this insomnia, that you want to get rid of it, that you want to be able to sleep better, and then you go through it again. All those points, you don’t have to do the karate chop point, but you go all through those points again, just saying how much you believe you can heal from this insomnia and you really want to be positively affirming and positively believing while you’re going through those acupoints that you truly are ready to heal. You can heal. You have all the necessary means to heal this sleep issue, and that’s it. And it usually takes like that obviously, it was longer, but it could take two to three minutes.

Audrey Wells, MD

Wow, that’s fantastic and free. And side effect-free, right?

Anna Esparham, MD

Yes.

Audrey Wells, MD

And you know, I kind of like that the person who is doing the tapping brings their shifted mindset to the table and gets an opportunity to practice that as well. So you said two to three minutes to go through this routine twice. What has been people’s experience in terms of how quickly doing this produces a benefit or helps them to feel better pretty immediately?

Anna Esparham, MD

So based on my experience for those people who are motivated enough to want to take care of their goal, so you really do have to have that motivation behind the goal. Everyone has had an immediate response and they continue with it. And even so, even the teens and I know teens are a very tough population to implement a lot of these mind-body therapies, but they actually loved it and they implemented it at home. I actually found the older adults have a little bit more trouble with tapping because of the difficulty remembering the points. And so I usually recommend for those individuals there is a free YouTube and a free website. I think it’s, yeah that thetappingsolution.com and there are some free videos on there so that it reminds them of those tapping points.

Audrey Wells, MD

I imagine too that you could even just draw a picture of the face and sort of mark those points as a reminder.

Anna Esparham, MD

Easy.

Audrey Wells, MD

Yeah. I want to sort of transition now to the practice of hypnotherapy. Can you describe what that is and how to know if you’re a good candidate?

Anna Esparham, MD

Yeah. So this is a very common misconception that most people, when they think about hypnotherapy or hypnosis, is they think of the performer that’s up on the stage using some kind of pendulum to hypnotize individuals so he or she can make them do whatever, like a clock like a chicken, for example. And that is not hypnosis or hypnotherapy. So that is more of a hypnotizing stage performance and doesn’t have any medical or health aspects to it. So hypnosis is using our creative imagination with also a goal in mind in a relaxed state. So it’s almost like meditation, but meditation with a goal while you’re daydreaming. 

And so the best example I can give is one of my patients who, for example, wanted to get rid of her headaches. She was able to go into a trance state, which is a very relaxed, focused state. So we’re all in a trance state when we’re doing sports, for example, or we’re highly focused on a project that intense, relaxed focus is almost like a trance state. And so when you get into that state, then the next step is being in a very protected, safe, special place that’s unique to you. And then you imagine, for example, this child, she imagined being at Disneyworld, which was her favorite safe place, and she put all her headache pain into all the Disney fireworks that go off every day. And every night and put her headaches in there and let them blow up in the air. 

So it was almost like her headaches were just blowing up and the pain was no more. It just dissipated with the fireworks. And so what happens with the body is that physiologically those pathways, those pain pathways, those emotional pain pathways that actually caused the chronic pain tend to visibly agree with that creative imagination that visualized action that goes on in that relaxed state. And somehow it changes our physiology in our own body, decreasing the headache pain levels. So it’s pretty fun. It’s pretty interesting. It’s a lot more easy for people to do hypnosis in terms of my practice that I have seen because it’s a lot more fun. People who can daydream, people who can imagine, have a little bit more fun than just deep breathing and going into the void with meditation techniques. So yeah, that’s a little nutshell of hypnosis.

Audrey Wells, MD

That’s fantastic. And I love that you mentioned fun bringing back some creativity, some imagery that is pleasant in the course of healing. I think that if you don’t do that, you’re missing a chance to kind of ease somebody’s burden as they’re trying to get through this. And I love the firework imagery. I would imagine you get to hear some really creative things that people come up with.

Anna Esparham, MD

Yeah, it is super fun. And then I take some little tips from them and I’m like, Oh, I should probably use that too, because they just come up with some amazing things and the kids. So when you said like, who is hypnosis for so kids can use it, kids usually it’s like seven and up. They really have to be able to identify their goal. They have to be able to have a focused daydream and be able to visualize that and be able to be relaxed and take cues and commands. Because with the clinical hypnotherapist, what I am doing is just giving them a little bit of cues and language, not for them to totally command their hypnosis state, they have to actually create it themselves. So we have to use what we call hypnotic language and we just have to be careful so that we’re not suggesting anything that the patient doesn’t want. So what I found is that up from age seven and above, through adulthood, good, is anyone can really be using hypnosis and self-hypnosis actually. So you can actually be taught this and do it yourself. And to be taught this, it doesn’t take that long. Usually, it’s about three sessions with a hypnotherapist or someone who is certified in clinical hypnosis. Three sessions is usually all it takes in terms of what I have seen in my practice, and then they can take it away. Sometimes they might need a little tune-up here and there if they get stuck, but otherwise they can practice it daily. Typically, the institutes usually recommend twice a day practicing your self-hypnosis and it can take five to 10 minutes twice a day. So really quick.

Audrey Wells, MD

Quick and pleasurable, you know, it’s getting you into a relaxed state. And one of the things that I like to point out for people who have trouble with sleep is that the more you can practice deliberately entering that relaxed state of calm and even a bit of pleasure, the more you’re going to lay the groundwork for healthy sleep and also trust in your sleep, I really love that.

Anna Esparham, MD

Yeah. Perfect.

Audrey Wells, MD

I want to wrap up with maybe some discussion about your work with aroma therapy, especially as it pertains to sleep.

Anna Esparham, MD

Yeah. So aroma therapy is a pretty powerful ancient medicine and so we have to treat it as such. And I know a lot of people who are certified in aroma therapy are using a lot of these essential oils. But we have to be careful because they are significantly powerful and they can have significant side effects. So I just wanted to add that disclaimer because we need to use aroma therapy appropriately. And there are many, many studies on aromatherapy, especially in the age of antimicrobial resistance. And hopefully, one day we’re going to discover this might actually be adjunctive for that, but also for sleep issues. And we use this for people with chronic pain. So aroma therapy, the biggest essential oil that has been studied for sleep issues, particularly insomnia, and insomnia in the general population, but also insomnia and sleep disturbances for menopausal women. So highly study. I think there’s actually been a systematic review, I believe for it. The lavender is the most studied essential oil and this actually can help moderately benefit your sleep quality of life per some small, randomized controlled trials, the diffusion of aroma therapy. So that’s putting the essential oil in a diffuser has significant benefits but also there have been some benefits associated with massage using the essential oil lavender. Now, lavender, when, you buy lavender, essential oil, 95% of the essential oils on the market are synthetic. And so they are not going to have any health benefits. In fact, they may harm people and they can cause headaches and they can cause certain sensitivities. And so what you want to look out for when you’re buying essential oils is it really has to have the name, the Latin name, or the botanical name. So for Lavender would be lavandula angustifolia, and it has to say it 100%. So it’s got to have 100% of the botanical name. Otherwise, it could be totally synthetic. So we do have to buy the right essential oils and use them correctly. And the other thing that you have to be aware of, is people who have insomnia or have had chronic insomnia. And so typically with aromatherapy, you don’t want to use the same essential oil nightly for more than two weeks in a row. So you have to back off because there can be some hormonal effects from lavender and so you don’t want to use this chronically.

Audrey Wells, MD

Got it. That’s really concrete information that people who may be thinking about aromatherapy or already using aromatherapy can take into account as they go forward. I really like that. I want to summarize what we’ve talked about today so that we can get really clear on the value that you’re bringing to the table and your areas of expertise. So we talked about the bi-directional relationship between sleep and pain. Problems with sleep can exacerbate pain issues and of course, pain can interfere with sleep quality. So really addressing both condition ends even simultaneously can have positive effects and even synergy. So I’m really happy to make that connection for people. You also have highlighted the impact that a patient’s willingness to come to the table to find some goals for themselves and practice these techniques on a daily basis is really key not only to implementation but to also reap the benefits as they’re learning, techniques like tapping, techniques like hypnotherapy or engaging in aroma therapy. The resources that you mentioned were thetappingsolution.com, and also pointing out that using aromatherapy like lavender for up to two weeks would be okay for sleep. Beyond that, you may see some side effects and you’re going to want to look for non-synthetic forms of essential oils to really get that benefit. As we wrap up, Dr. Esparham, I wonder if there’s anything else you’d like to share. I would really like to know where people can find you and learn more about your work.

Anna Esparham, MD

Yeah, the first thing I want to share is that it takes a little bit of time and effort to help with a lot of these chronic conditions, sleep or chronic pain and both, and usually trying some of these different techniques. You know, we just mentioned a few of them today, but there are several others. And so go on a search, look at mind-body therapies for pain, for sleep, and just try some out for yourself. It’s not a one-size-fits-all or seek a practitioner in your area that’s certified and for many of those that were mentioned today you guys can find me I’m at healthispowher.com. So it’s POWHER, and I work with a lot of women who have chronic issues like chronic pain and autoimmune disease, and chronic fatigue. And I also have a podcast, The Health is PowHer, podcast as well, which we have featured you, Dr. Audrey Wells. And so you can check that out as well.

Audrey Wells, MD

It was so fun to be on your podcast and I really like talking to you because I think we both share a need to collaborate with our patients to engage them in a human way. And it was such a pleasure to speak to you today. Thanks for bringing your expertise.

Anna Esparham, MD

Thank you so much.