Massage Today Get the Latest News FASTER - View Digital Editions Now!
Massage Today dotted line
dotted line

dotted line
Share |
  Forward PDF Version  

Inside-Out Paradigm

By Dale G. Alexander, LMT, MA, PhD

About the Columnist
Other Articles

Sleep Deprivation

Perpetuates anxiety, panic attacks and chronic pain.

"If burnout is civilization's disease, sleep deprivation is one of its chief symptoms."1 To sleep soundly and awake feeling rested is one of life's true pleasures and blessings of experiencing our innate human capacity to restore and heal. Sadly, this nightly restoration eludes so many of our clients. And tragically, it is "under-appreciated" as a significant variable among those who suffer with chronic pain, anxiety, and panic attacks. Varying levels of insomnia and other sleep disorders, which create sleep deprivation, effect all ages for many reasons. So, the first encouragement of this article is for you as a practitioner to ask of each of your clients one simple and very important question: "How well do you sleep?"

Over my 36 years of clinical practice, I have come to the understand that sleep deprivation related to sleep disorders and insomnia are associated with most chronic problems that clients have presented to me, and particularly for those who experience chronic anxiety and panic attacks - the correlation of those with sleep difficulties is almost 100%.

Sleep Deprivation - Copyright – Stock Photo / Register Mark During the past three decades, I have seen many teenagers and adults who presented with bizarre patterns of behavior who have been medically diagnosed with anxiety disorders and panic attacks and whose condition consistently has distilled into one common problem: "not enough sleep" or "sleep deprivation," as the more formal term. This is after they had sought treatment from many other health professionals whose diagnoses had traversed the gamut of possibilities; yet, had missed this most common sense source of their many psychological and physical problems.

Please consider that within your first three questions when interviewing any client with chronic somatic difficulties, or anxiety and/or panic attacks for the first time that you ask the paired questions, "How well do you sleep?" and, "Do you awake feeling rested?"

Not all will tell the truth. Yet, the questions open the door to consider how the lack of good quality sleep is related to whatever problem has brought them to see you. Many live with sleep deprivation and do not recognize it as a problem. When was the last time your doctor asked you, "How well do you sleep ?" Of course, we all have a restless night from time to time with concerns over loved ones or in response to the state of our world in its tumultuous transition at seemingly every level presently. There is much to realistically kvetch about.

I am strongly suggesting that highlighting and emphasizing the importance of sleep is crucial to assisting your clients. Most often relating your own bouts with sleep difficulties is more influential than any statistical factoid. Encouraging them to drink more water and ingest natural sources of electrolytes regularly helps as well. Client education via our embodied presence as real people (which means encouraging them to see that we are human, too) is what influences and motivates our clients most effectively.

The behavioral patterns associated with sleep deprivation in people suffering from chronic conditions are usually ingrained and subconscious. Sometimes they exclaim, "I've slept badly for as long as I can remember." In response, I have discovered that compassionate and persistent persuasion is required for them to realize its integral relationship to their presenting dilemma. The most consistent symptoms related to chronic problems and anxiety disorders include, "I hurt." "I have no or little energy." And, "I can't move as I need or want to."

For most, three to five nights of quality sleep produces results in all three of these categories that they notice and like. And, if their improved sleep pattern and our bodywork together doesn't bridge the gap, I frequently encourage clients to see their physician.

Clients often experience difficulty in falling to sleep or experience waking up periodically throughout the night. These are the bookends of sleep deprivation. Many individual scenarios exist and vary between these two reference points. Whatever is required, whatever is effective; that is the place to start - whether it is a change in habit or a physician's prescription. Medications can have an effective, rightful place within a preferred trend toward returning to more natural and nutritionally based support for normal behavioral and physiological function.

Research associated with fibromyalgia, one of the well-known chronic conditions I often see, has highlighted the importance of adequate sleep and rest.2 It has been known for a long time that at least four hours of sleep is required for muscle/connective tissue repair on a daily basis.3,4 I do use this standard as a foundation from which to help clients to set a goal of sleeping longer regularly. And if a high frequency of nocturnal urination is a sleep disruption factor, consider it a flag for a referral to a urologist.

What might we do as massage therapists beyond raising our client's consciousness about their body and its functioning, encouraging them to further educate themselves, or suggesting they see their physician? Understanding and appreciating the central influence of the reticular activating system (RAS) is the cornerstone to comprehending sleep difficulties. The RAS, "is a set of nuclei in the brain of vertebrates that is responsible for regulating wakefulness and sleep-wake transitions." It extends from the brain stem into the midbrain (including the thalamus and hypothalamus).5,6 However, most of the research and reference information about the RAS focuses on how these nuclei respond to chemical mediators which modulate the electrical activity of its functioning.

Very little attention has been given to how influencing increased blood and neural flow to, from, and between these structures may assist, or not. This is where our touch skills can assist. Toward this therapeutic intention, creating space is the theme, space between the interface of the cranium and upper cervical spine, and space within the cranial vault and within its relationships to the face, throat, and especially space for the better functioning of the TMJ.

One original technique that spontaneously guided my hands many years ago which can significantly decompress the TMJ involves placing your gloved and kleenex-wrapped forefinger in the client's mouth back to their first molar tooth while contacting the lateral side of their mastoid process of the temporal bone on the same side with your other hand's thumb and forefinger. Asking the client to watch your eyes in order to clearly communicate any signs of distress, request that they slowly begin to add pressure to your finger from both sides as you softly guide the temporal bone medially. Very quickly, in most instances, you will feel a giving of the TMJ surfaces and a release of the pressure within this crucial joint.

This manipulation is what Osteopath's call a shotgun technique, and its effect is often immediate and positive in that it creates the sensory experience of space within the joint and throughout that side of the face. Sometime clients report that they can breathe easier through their nose and open their mouth more easily and with greater range of motion.

I propose that reducing compression and congestion throughout the head, neck, and face allows an easing and improvement of blood and neural flow. As congestion within these areas is reduced, then a re-coordination of autonomic neural activity becomes more possible.7 This is the essence of what my clinical experience has shown to be effective for clients.

In a future article, I will outline more of the anatomical structures that I have discovered are most directly related to regaining a normal sleep pattern and restoring balance between the two divisions of the autonomic nervous system. Many will relate to the cranial vault, face, jaw, throat, and upper cervical vertebrae.

The two goals of rebalancing the TMJ and of restoring ANS coordinated functioning are inextricably woven together in the quest to normalize the function of the RAS. Without a more normal sleep pattern, chronic dysfunction, pain, anxiety, and panic attacks often function like a roving brown-out as when the capacity of a community's electrical distribution system is impaired. All customers get some electrical service, but not enough for full and normal activity. And so it is with the human body when a "neurovascular brown-out" occurs. One's quality of life diminishes quickly without adequate sleep.

Recently, Dr. David Brownstein, MD, included a natural protocol for addressing sleep disorders and insomnia in his April 2016 Natural Way to Health newsletter. He recommends the use of melatonin, beginning with a low dose of 0.5 mg that can be raised gradually to 3 mg. He also recommends the amino acid 5HTP at 200 mg, noting that it can be converted into natural forms of serotonin and L-tryptophan. The last of his natural triad involves the use of GABA (gamma amino-butyric acid) at a dose of 1000 mg to assist in calming the brain. All of these to be taken at bedtime.8

Our license as massage therapists does not allow us to recommend such regimes, per se; however, we can speak to our own personal experience, the successful experience of other clients, or to point our clients toward articles such as this one summarized here. Two additional links are included that suggest some precautions regarding the use of GABA.9

Calming the brain appears to be the most crucial element to breaking the insidious cycle of insomnia and sleep disorders that lead to sleep deprivation. Behaviorally, sleep research advocates suggest that creating a "routine of behaviors" that calm one's body and mind is most often successful in one's attempt to normalize their sleep pattern. Turning off all electronic devices and TV is considered an essential step to increasing the success of such a routine.

There are many websites that offer tips for achieving better sleep. One idea I plan to implement is to create a printed page listing the ones containing information that make the most sense to me and give it to clients when appropriate. Included in these recommendations will be an encouragement to see their physician. Anything that expands our client's informational perspective and is tangible adds to our credibility and effectiveness as educators, as well as practitioners. Please consider doing this for your clients.

During my research for this article, three novel recommendations enlightened me. These included the ideas of lowering the temperature of one's bedroom to 65-67 degrees F, creating one's "to do list" for the next day "an hour before bedtime," and going to bed and awaking at the same time each day. Although, living in the Florida Keys as I do, 65-67 degrees seems too cool, it is a concept that instinctively makes sense to me, as did the other two suggestions.10

The first recommendation is based on a study that asserts that regulation of body temperature and sleep are two physiological mechanisms that are vital for our survival. Interestingly, the neural structures implicated in both these functions are common.11

Another recommendation I often suggest that was found in only a few of these many websites is to encourage clients to consider purchasing a new bed if theirs is more than years old. Once I actually discovered that my box spring was broken directly beneath a shoulder that had been bothering me for many months. If you don't look, you won't know. And, regardless of the material construction of a bed, it will eventually break down, offering your body less balanced support.

An additional learning was that our circadian rhythm is principally triggered by light intensity, hence the common advice to keep one's sleeping quarters dark, and if reading is part of your bedtime routine, to use a low intensity source of illumination.12

In summary, the listing of the types and possible causes of insomnia and sleep disorders that produce sleep deprivation is far beyond a single article. Yet, each of us can make a difference as massage therapists by asking two simple questions of our clients, "How well do you sleep?" and, "Do you feel rested when you awake?" Heart-felt, common sense encouragements do influence our clients as does adding to their scope of understanding of the variables both anatomical and behaviorally. We are educators as well as practitioners. Encouraging our clients to seek medical advice and monitoring is a practical service to all clients.

Seek to comprehend the anatomy and physiology of the reticular activating system and its interface with the coordinated functioning of the autonomic nervous system, and learn techniques that may serve to synchronize their harmonious functioning. We can offer much more than we realize as a competent face and voice within the health care delivery system.

Sleep Tips

  1. Create a bedtime routine. Conceive of it as a ritual of self-care. Stair stepping your consciousness toward a more relaxed state is the essential theme.
  2. Make your bedroom comfortable by creating a dark, cool, quiet environment. Lowering the temperature and reducing light appear to be key elements to better sleep.
  3. Maintain a consistent Sleep Schedule of when you go to bed and when you wake up. This reinforces your body's sense of an internal circadian rhythm.
  4. Seek out sunlight when you wake up if possible and spend more time outdoors.
  5. Exercise Regularly. A morning walk of 20-30 minutes before breakfast has many benefits to your health, as does yoga stretching.
  6. Turn off electronic devises as you implement your bedtime routine including the TV. Some suggest as much as two hours before.
  7. Be smart about what, how much, and when you eat. It's a Goldilock's theme. Some do best with a light snack before bed like a slice of apple and a bit of cheese.
  8. Reserve your bed for sleep and sex. Positive associations pay off.
  9. Make relaxation your goal.
  10. Create your "to do list" an hour before bedtime. Allow yourself to meditate or pray.
    Consult your physician if these and other ideas don't work. Restful sleep is essential to healing and to maintaining your health.


  1. The Sleep Revolution, Arianna Huffington, Cristabella, LLC, 2016.
  4. Complimentary and Integrative Medicine in Pain Management, edited by Michael Weintraub, M.D., FACP, FAAN, 2008, Springer Publishing Company LLC. pg. 371
  5. and
  7. A Look at Compression, Congestion and Dis-Coordination, Massage Today, August, 2014 (Vol. 14, Issue 08)
  8. Dr. David Brownstein's Natural Way to Health, April 2006, Vol. 9, Issue 4.
  9.  and
dotted line