If you have surgery to repair a broken foot and then it hurts or rebreaks after you decide to go jogging prematurely, does that mean the surgery was ineffective? If you have a wound cleaned out and you decide, against orders, to go for a swim and it gets infected again, does that mean the debridement wasn’t effective? The intervention is the surgery, but it’s also the instructions that come with it. The intervention is the wound debridement, but it’s also the accompanying directions.
With physical therapy interventions I tend to give patients 1-2 things to do as well as 1-2 things to modify or avoid. Could I give more things to do and more things to avoid? Yes. But people don’t tend to follow a longer list of instructions, so keeping things simple is key. Say, though, to fix your elbow pain you seem to need repeated elbow extension and you wake up one day and symptoms are worse. We need to be critical thinkers. Is it possible the intervention of elbow extension is wrong? Yes. But if you were good before bed and you woke up worse, it’s more likely that sleeping interfered with your intervention rather than the intervention is wrong. When sleeping, we adopt postures unconsciously. It’s quite likely your elbow was simply in a position that made it worse. We need to figure these kind of things out.
There are plenty of examples of things that can interfere. It’s hard to foresee and prevent ALL things that may impede an intervention from working. But when they arise, we need to recognize them for what they are and not simply disregard an intervention that has the potential to work if given the right circumstances. -- Laura
It’s not uncommon that sleeping makes problems worse. That is, symptoms become exacerbated and/or movement becomes limited. Morning stiffness to a small extent is allowable when it comes to spinal flexion, but, otherwise, after being up and about for a few minutes, you should have the same amount of mobility you went to bed with.
During sleep, we often spend considerable time in one position without moving - whether we want to or not. It is my opinion that most orthopedic problems are related to movements and postures, so it makes sense that, just like with sitting or walking, sleeping postures can easily make people worse (or better).
If the thought process is that people need muscular strength to “hold” or “stabilize” joints in the right position, then there must be profound weakness if the simple act of sleeping causes joints to destabilize. Similarly, sleeping should not be aggressive enough to strain/pull muscles.
My thought process is this: I agree healthy joints should be able to withstand prolonged positions while sleeping, but I don’t think the answer is muscle-driven stability. And I don’t think muscles get pulled in our sleep. Benign positions like sitting or lying can indeed move joints - regardless of how much muscle is nearby. And these subtle changes can commonly cause symptoms. On the whole, strength is wonderful, but I believe we need to get the joint better first by moving the joint itself.
It’s true that spinal discs enlarge when we lie down to sleep, and that may be the sole factor why someone has more pain and/or less motion upon waking (vs related to any certain position). But even if that is the causative factor, then, again, I want to primarily address the disc (part of the joint) versus address the musculature around it. It’s also true that not all orthopedic problems are joint problems. Sleeping on a painful tendon can worsen symptoms, too. But most problems do have to do with joints - and addressing them effectively is important. -- Laura
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