Want To Heal Yourself Faster? Do This!

Sleep: the elixir of healing (and life!)

Julian Kuz, M.D.

Many patients ask me if there is something they can do to promote healing after injury or surgery. They are thinking that there is a dietary change (can I take more calcium?) or a therapy program that will speed things along. Being an orthopaedic surgeon, I treat a variety of injuries and perform surgeries that would benefit from optimal healing. We often discuss measures such as appropriate therapy, smoking cessation, and nutritional aspects. However, there is a step that patients can take that may be one of the most important actions they can take to improve healing.

They are surprised when I answer “improve your sleep pattern and/or quantity.” Yes, your mother was right! Yet, this answer goes beyond motherly advice and has excellent science to support it. In fact, it likely trumps all other factors as being the cornerstone to the healing process.

So what does the science of sleep say about healing? The effects of sleep improve aspects of the immune system, tissue adaptation, and pain reduction. Significant healing processes begin with the onset of sleep. In essence, this is when the repair crews of the body get out to do the most work. As it turns out, sleep affects your ability to heal through multiple mechanisms: immune system function, wound healing capabilities, adaptation response during the strengthening phase of rehabilitation, pain reduction, and accident avoidance (a not uncommon problem for patients-falling on their surgical site or injury!). In addition, the quality of resiliency which is fundamental while trying to heal from an injury or surgery is also affected by sleep. I will go through each of these below and provide references for those who are interested in learning more. This is but a small number of studies of the hundreds that support these points.

As we all know, wound healing is substantially worsened by infection and our immune system is our defense against this problem. Sleep affects the immune system immensely. Numerous sleep studies show that the lack of sleep renders your immune system much less effective making you more vulnerable to infection and delayed wound healing. “The integrity of the immune system is indispensable during the healing process, particularly during the recovery of tissue after burns, when defense cells and inflammatory mediators act in unison to promote tissue regeneration, cytokine production, and bacterial clearance…..These results suggest that a few hours of sleep deprivation is sufficient to cause adverse effects on the integrity of the immune system.”1 Recently, researchers have been able to identify the body’s sleep-enhanced pathway for doing this. “T-cells” are one of our primary infection-fighting cells that help identify the infection and begin the response of our immune system. The recent research shows that volunteers that sleep had significantly higher activation response of T-cells through a complex interaction of hormones and other molecules compared to volunteers that were kept awake.2

It is easy to understand that with the sleep enhanced effect of infection reduction mediated by the immune system, that the speed of healing tissues would also be affected given that this action is also influenced by the immune system. Healing tissues need improved blood supply and cells that produce collagen (a building block for tissue repair) called fibroblasts. Animal studies have shown that sleep deprivation reduces capillary in-growth and fibroblast production.3 Fibroblasts are integral for wound healing. This effect has also been studied in humans.4 This study used volunteers that were given blisters and then split up into a group that was allowed to sleep 7-9 hours/night and a group that was placed into sleep deprivation. This showed that sleep compared to sleep deprivation improved healing rate by up to 15%. An additional finding was that nutritional supplementation did not speed up the healing in the sleep-deprived group. This shows that you cannot overcome wound healing delay from sleep deprivation simply by better nutrition or supplementation.

Another critical factor for healing and recovery from injury or surgery is the ability to perform effective rehabilitation. I have observed that patients learning therapy exercises often forget instructions given by therapists. This can cause anything from ineffective therapy to outright damage to the healing area. Appropriate sleep will enhance not only the skill of performing a muscle related task, it will improve retention of the critical components of the task.5 This makes home exercise that most patients are given more effective and safer. The ineffectiveness of rehabilitation in a patient that is sleep deprived is multifactorial as many more aspects are affected such as pain levels.6

The association between sleep and pain are strong. Researchers have discovered that it is a two-way street. Pain will affect sleep, but sleep will also affect pain. A number of studies have used sleep deprivation as a tool to determine that it worsens pain.7 The ability to tolerate pain will affect wound healing, compliance to therapy, and the ability to remain resilient-a psychological advantage for getting through the healing process. Prolonged pain creates psychological stress which will reduce healing times by up to 25%! Multiple studies have shown prolonged healing times due to this factor.8 The ability to use sleep as a tool to reduce pain would not be lost on any of us that have seen issues with the use of opioids for pain reduction and the subsequent epidemic upon our nation. Opioids, commonly used after major injury or surgery, interfere with sleep with the resultant loss of benefits that sleep confers upon healing.9

As a surgeon, I have counseled patients on accident reduction, especially for the elderly who are at particular risk for falling. There can be many aspects in accident reduction. Sleep deprivation is a well known factor in accident causation. I have had the unfortunate experience of having a number of patients over the years who have fallen upon their injury or surgical site and have made the problem decidedly worse or substantially delay their recovery. These falls have been associated with further fractures, disruption of surgical repairs, premature opening up of wounds, and wound infections. Better sleep is an important factor to help reduce the incidence of this problem.10

Finally, there has been increased awareness on how the concept of resiliency affects our ability to bounce back from adverse life events such as an injury or surgery. Improved resiliency will help maintain or reduce the negative consequences that can occur while trying to heal including our relationships, finances, development of chemical dependency, and general feelings of wellness and happiness. The military has taken special interest in the phenomenon of resiliency and there is research that supports that improved sleep will improve resiliency.11

So, ultimately if your repair crew needs 8 hours to get ahead on the job (healing) and you are only giving them 5 or 6 hours sleep to let them do their work, guess what? Expect your pain to be worse, healing to go slower, and progress in therapy to be reduced. All of these factors can potentially reduce your resiliency and increase your chances of an accident.

Unfortunately, mentioning that sleep is the holy grail of improved healing to patients is sometimes met with resistance. Too often, patients and doctors are operating with long held social beliefs and customs suggesting that sleep is somehow optional or for the lazy. This belief is especially held true by much of the business community and even extends to parents and their attitudes towards their children’s sleeping habits (“The early bird gets the worm!”). Our modern day work and life styles betray the obvious health benefits of sleep. Another aspect is the fact that sleep is viewed as a passive rather than active intervention. People looking to improve healing are feeling they need to actively pursue something and sleep tends to be viewed as a passive activity and many have been taught erroneously that it can be easily sacrificed for other goals. They would prefer that I say that there is something like a nutritional change or supplement that could have a profound affect on healing. While those elements would have a small incremental affect, they do not trump the benefit of sleep for healing. Unfortunately, the more type A behaviorally you get about trying to sleep, the more it becomes counterproductive.

The bottom line? In addition to being compliant with your doctor’s recommendations of follow- up and therapy, improving your sleep is the single most powerful thing you can do to heal faster. Your mom was right. Go to bed!!

The ability for how to improve your sleep goes beyond the scope of this article but for those that are interested, this article can act as an initial reference.. https:// advancedtissue.com/2015/04/tips-for-improved-wound-healing-through-better-sleep/

If you want to learn more about how sleep profoundly affects almost all major aspects of our overall health, an excellent book on the topic is Why We Sleep: The New Science of Sleep and Dreams by Matthew Walker

1 Wound-healing and benzodiazepines: does sleep play a role in this relationship? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400176/

2 Gαs-coupled receptor signaling and sleep regulate integrin activation of human antigen- specific T cells. http://jem.rupress.org/content/early/2019/02/11/jem.20181169

3 Effects of Sleep Deprivation, Nicotine, and Selenium on Wound Healing in Rat. https://doi.org/10.1080/00207450490509168

4 Impact of sleep restriction on local immune response and skin barrier restoration with and without “multinutrient” nutrition intervention. https://doi.org/10.1152/japplphysiol.00547.2017

5 It’s Practice, with Sleep, that Makes Perfect: Implications of Sleep-Dependent Learning and Plasticity for Skill Performance. https://doi.org/10.1016/j.csm.2004.11.002

6 Consideration of sleep dysfunction in rehabilitation. https://www.ncbi.nlm.nih.gov/m/pubmed/21665101/

7 Pain reduction. The association of sleep and pain: An update and a path forward https:// http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046588/

8 The Impact of Psychological Stress on Wound Healing: Methods and Mechanisms. https:// http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052954/

9 Opiates, Sleep, and Pain: The Adenosinergic. http://anesthesiology.pubs.asahq.org/ article.aspx?articleid=1932593

10 Falling-Asleep–Related Injured Falls In The Elderly. https://doi.org/10.1016/j.jamda.

2008.10.008

11 Sleep and Resilience—A Call for Prevention and Intervention. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835317/#!po=1.72414