Pain never sleeps: why and how to integrate sleep management in the treatment for patients with chronic musculoskeletal pain

Jo Nijs1,2,3 & Anneleen Malfliet1,2,4

1 Pain in Motion International Research Group,, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Belgium

2 Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium

3 Department of Neuroscience and Physiology, University of Gothenburg, Sweden

Research Foundation – Flanders (FWO), Brussels, Belgium

twitter: @JoNijsBE


Lifestyle factors such as sleep problems, physical (in)activity, sedentary behaviour, stress, unhealthy diet, and smoking are associated with chronic musculoskeletal pain severity and sustainment1-5. Yet current treatment options often do not, or only partly address the many lifestyle factors associated with chronic musculoskeletal pain1,5-7. Therefore, this course focusses on one key lifestyle factor that is often overlooked and rarely addressed thoroughly: sleep. Among many people with chronic musculoskeletal pain, including patients with osteoarthritis, low back pain, neck pain, temporomandibular disorders, shoulder pain, post-cancer pain, neuropathic pain, headache, and fibromyalgia, insomnia is highly prevalent, closely related to the mechanism of central sensitization, characterized by low-grade neuroinflammation8, and often does not respond effectively to drug treatments9.

This course applies the current understanding of insomnia to musculoskeletal clinical practice, including assessment and conservative treatment of insomnia in people with chronic musculoskeletal pain10. Cognitive behavioural therapy for insomnia (CBT-I) can be efficacious in improvements of sleep initiation, sleep maintenance, perceived sleep quality and pain interference with daily functioning in people with chronic musculoskeletal pain. With additional training, musculosleletal physiotherapist-led cognitive-behavioral interventions are efficacious for spinal pain, allowing their implementation within the field. CBT-I, as provided to people with chronic musculoskeletal pain, typically includes sleep education, sleep restriction measures, stimulus control instructions, sleep hygiene, and cognitive therapy11.

The treatment of sleep disorders as highly prevalent and debilitating comorbidity of many musculoskeletal pain disorders is an exciting, innovative area for the musculoskeletal physiotherapy profession. This new development holds great potential for improving care for the many patients with persistent musculoskeletal pain who have sleep problems.   

Learning objectives:

At the completion of this course, learners will be able to:

  1. Identify patients with musculoskeletal pain who require sleep treatment;
  2. Perform relevant sleep assessments in patients with musculoskeletal pain who require sleep treatment;
  3. Improve their clinical reasoning by integrating sleep problems into their clinical reasoning process for patients with chronic musculoskeletal pain;
  4. Treat common sleep problems in patients with chronic musculoskeletal pain;
  5. Integrate sleep treatment into more traditional musculoskeletal physiotherapy approaches such as education and exercise therapy, in order to design individually-tailored multimodal treatment approaches for people having chronic musculoskeletal pain.


09.00 Introduction

09.15 The role of sleep problems in patients with chronic musculoskeletal pain

11.00 Coffee-break

11.15 Identification and assessment of patients with musculoskeletal pain who require sleep treatment: skills training using case studies

13.00 Lunch

14.00 Treatment of sleep problems in patients with chronic musculoskeletal pain part 1: sleep education and sleep hygiene

15.30 Coffee break

15.45 Treatment of sleep problems in patients with chronic musculoskeletal pain part 2: sleep restriction therapy and combining sleep treatment with educational and exercise interventions

17.00 End of course

Educational modes:

The course content will be delivered through a mixture of methods, including:

- interactive lectures
- demonstrations
- practical skills training
- illustrations
- case studies

The course uses a combination of educational modes in order to optimize implementation in clinical practice and to address implementation barriers12.

Key references

  1. Nijs J, D'Hondt E, Clarys P, Deliens T, Polli A, Malfliet A, Coppieters I, Willaert W, Tumkaya Yilmaz S, Elma Ö, Ickmans K. Lifestyle and Chronic Pain across the Lifespan: An Inconvenient Truth? PM & R : the journal of injury, function, and rehabilitation 2020; 12(4): 410-9.
  2. Malfliet A, Marnef AQ, Nijs J, Clarys P, Huybrechts I, Elma Ö, Tumkaya SY, Deliens T. Obesity Hurts: The why and how of Integrating Weight Reduction with Chronic Pain Management. Physical therapy 2021.
  3. Vitiello MV, McCurry SM, Shortreed SM, Balderson BH, Baker LD, Keefe FJ, Rybarczyk BD, Von Korff M. Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial. Journal of the American Geriatrics Society 2013; 61(6): 947-56.
  4. Okifuji A, Hare BD. The association between chronic pain and obesity. Journal of pain research 2015; 8: 399-408.
  5. Torres-Ferrus M, Vila-Sala C, Quintana M, Ajanovic S, Gallardo VJ, Gomez JB, Alvarez-Sabin J, Macaya A, Pozo-Rosich P. Headache, comorbidities and lifestyle in an adolescent population (The TEENs Study). Cephalalgia : an international journal of headache 2018: 333102418777509.
  6. Nijs J, George SZ, Clauw DJ, Fernández-de-las-Peñas C, Kosek E, Ickmans K, Fernández-Carnero J, Polli A, Kapreli E, Huysmans E, Cuesta-Vargas AI, Mani R, Lundberg M, Leysen L, Rice D, Sterling M, Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. The Lancet Rheumatology 2021; 3(5): e383-e92.
  7. Gutke A, Sundfeldt K, De Baets L. Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions. Journal of clinical medicine 2021; 10(22): 5397.
  8. Nijs J, Loggia ML, Polli A, Moens M, Huysmans E, Goudman L, Meeus M, Vanderweeen L, Ickmans K, Clauw D. Sleep disturbances and severe stress as glial activators: key targets for treating central sensitization in chronic pain patients? Expert opinion on therapeutic targets 2017; 21(8): 817-26.
  9. Nijs J, Mairesse O, Neu D, Leysen L, Danneels L, Cagnie B, Meeus M, Moens M, Ickmans K, Goubert D. Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Physical therapy 2018; 98(5): 325-35.
  10. Herrero Babiloni A, Beetz G, Tang NKY, Heinzer R, Nijs J, Martel MO, Lavigne GJ. Towards the endotyping of the sleep-pain interaction: a topical review on multitarget strategies based on phenotypic vulnerabilities and putative pathways. Pain 2021; 162(5): 1281-8.
  11. Van Looveren E, Meeus M, Cagnie B, Ickmans K, Bilterys T, Malfliet A, Goubert D, Nijs J, Danneels L, Moens M, Mairesse O. Combining Cognitive Behavioral Therapy for Insomnia and Chronic Spinal Pain within Physical Therapy: a Practical Guide for the Implementation of an Integrated Approach. Physical therapy 2022.
  12. Stander J, Grimmer K, Brink Y. Training programmes to improve evidence uptake and utilisation by physiotherapists: a systematic scoping review. BMC medical education 2018; 18(1): 14.