| I was an orderly in a physical therapy department at the age of 16. This was a good job for a number of reasons, not the least of which was that I never had to work weekends. In fact, therapy was not provided on weekends in most places with any regularity until I was in practice a few years.
I graduated from school during the golden age of modalities. We were taught that primary problems of pain should be treated as if they were always concurrent with tissue injury, and my job was to promote healing by drawing blood to the painful part. I didn’t need skill so much as I needed electrical outlets.
Anyway, I entered practice having been given two distinct messages: real pain and injury were always concurrent and therapy was provided only during weekdays after sun-up.
Once in practice, I was soon faced with two new facts: significant tissue damage was commonly absent in chronic pain and people often needed therapy when darkness fell. In fact, night was the worst time for many of my patients and it remains so today.
Karen Fiser, in a wheelchair and chronically in pain, has expressed her ordeal in an amazing book of poetry entitled Words Like Fate and Pain. In “Night Shift,” she writes in part:
How many times have you heard, “I wish you could have seen me about 3:00 a.m. this morning!”?
Fiser’s poem graphically describes the rise in sympathetic tone that peaks by 4:00 a.m. (half the night) and is present in all of us. As I grow colder, another blanket will help, but those with irritated nervous tissue lose the adaptive potential that makes sleep possible at 11:00 p.m. Now they are faced with pain that defies a simple change in position. They have to shift their physiology and this means they have to get up and move. They wonder: What have I done wrong? Which way can I lie comfortably? Is it time for another pill? They wish the therapist could see them now.
What would my practice be like if I began seeing patients at 11:00 p.m.? I think that the same people I see in the daylight with their comments on the weather, their jobs, or the traffic, would speak of issues more personal and closely connected to their pain. The unconscious normally rules at night, and if I want instinctive movement and less posing from my patient I will probably find it easily at 2:00 a.m.
Karen Fiser may not know why pain often increases at night. I would guess no one has told her of the relation between physiologic state and nociceptive firing. But she knows that the night offers a time to change that is more profound than anything that happens in the glare of the clinic’s light. In the final verse she states this starkly:
Maybe if therapists understood as much about the night and what a dangerous opportunity it offers, we could help more during the daylight.