Sleep, Neuroplasticity, and POTS: Why Your Brain Needs Sleep to Heal

We often think about sleep as just kind of being not conscious, right? And while that is true, it doesn't really grab the depth of what it means to be asleep. Sleep is a vital function. We don't do great when we don't sleep very well. Most of you know that. And if there was a drug in the world that could give you all the benefits that sleep gave you, it would be priceless.

So if we start from there, we know pretty quickly that if we can impair sleep, then we're not going to get to full function. If we're already struggling, not feeling well, now we're in a position where it gets even harder to recover. It's not rest. It's not conserving energy. It is a highly regulated, metabolically distinct, and actively restorative process.

Your Brain Has Its Own Sleep Architecture

Your brain goes through these cycles. We've got four main phases. We're going to break it down into REM and non-REM just to make it simple. They go through these very specific ranges on purpose. And what we're measuring is the frequency of brain waves.

If you think about music, you can have music that plays at different speeds, right? So you have rock music that plays really fast and you have classical music that plays really slow. And in order for them to work, all the different instruments within that song kind of got to be playing at the same pace, the same beat. And if they don't, it doesn't sound very good.

So what we can see is that there are these different cycles throughout sleep where your brain is going to play different music, so to speak. It's playing at different frequencies. And those different frequencies are associated with different parts of the brain and different pathways that are syncing up in those moments to do a couple different things.

Non-REM sleep is mostly these big long slow delta waves. This is where we kind of get the most restorative sleep. Now in REM sleep where we get the rapid eye movements, we actually have parts of the motor cortex and parts of the frontal cortex that are really active and it's almost like a rerun of some of the day's activity. The difference is that we inhibit everything in the spinal cord so that we don't move — and that lets us run the motor cortex and consolidate memory based on motor cortical activity but without actually activating the spinal cord.

The Three Jobs of Sleep

So sleep has got three tasks. Number one is memory consolidation. And this isn't just memories like, "Oh, I had a wonderful day today." It's also the memories of how did I navigate to where I was going, man it was cold today maybe I should dress warmer tomorrow. All of these little things are happening at the same time and so we have to consolidate them, but our brain has to decide which ones are the most important so that we can plasticize those and put more dominance into those particular patterns.

Number two is waste clearance. Super important. We've got all of these channels that help us take all of the byproduct of running a brain and flush it out. We call them paravascular channels. It basically takes and uses cerebral spinal fluid to push that back out. Very, very active pulsations in this system during slow-wave non-REM sleep. This flushes out the metabolic wastes — the misfolded proteins, amyloid beta, tau. So these are ones that are kind of associated with dementia, Alzheimer's, Parkinson's disease. All of the trash of running your brain, this stuff helps pull it out.

And number three is the energy reset. There is a measurable increase in production of energy — ATP — in wake-active regions during non-REM sleep. So you're actually burning energy, super active in those pathways of the brain while sleeping. It's not about saving energy, it's replenishing it. It's restoring all of that function that was used during the day for creating new pathways, creating memories, creating learning.

The Synaptic Homeostasis Hypothesis

OK so this is called the SHY hypothesis. To be able to run synapses during the day, you're going to end up with a net increase in synaptic potentiation. And what that means is like learning. As you do things throughout the day, your body's trying to remember them, recall them, learn them. And so certain synapses are going to be more active, right? The stuff we're doing more frequently becomes more active.

So you can imagine like if you take a whole forest of synapses and we just say some of those trees grow a little bit more than the others. So they kind of stick up. And eventually we get to the point where we get tired. Anybody who's ever done a ton of studying, you get to the point at the end of the night where you're like, "Nothing's going in my brain anymore. We're kind of done."

So slow-wave sleep basically downscales all of the less essential stuff. It takes the volume button and turns it down and pulls down everything all together all at once. But what that means is the ones that are more active end up having the spikes that are a little higher there, the trees that are a little bit higher — which comes next so that they can flag so that we can use those to help be restorative, consolidate memory, and use those so they'll be better on the next day.

Why Sleep Makes You Better at Things You Practiced

We need sleep if we're going to make new pathways. So let's say you have never touched a guitar before and you start learning how to put your fingers on the guitar. First time — whoa. Bad. Really bad. But what we find is that you can actually see improvements in the motor task by just practicing it and then going to sleep. People go to sleep, they wake up the next day and they're better at it. Even though they didn't practice it any more times.

Because they were allowed to let their memory consolidate that task — learn that task, put it into memory, commit it to memory — when we go back to try to run that pathway the next day, it's stronger because we've been able to rebuild all the structure underneath that. And if you practice it again and sleep again, it just keeps getting better and better and better.

What Happens When Brain Injury Disrupts Sleep

So this is what happens when we get our brain injury. This is what happens when we have dysautonomia or ME/CFS — now we have damaged or interrupted the sleep architecture. That might be in terms of the quality of your sleep. You might notice that it's harder to get to sleep. It's harder to stay asleep. You're more restless. You don't sleep as much or as long or you have to sleep way more but you don't feel rested.

It's both a symptom that most of you guys have talked about — and I have that conversation every day — but it's also a driver. So if you think about on the one end, I've got my brain and when I'm awake is trying to do stuff and I'm not doing great and that makes me symptomatic. But on the back end of that, sleep isn't just throwing in the towel and being done with the day. This is a continuation of processes for our body. Our body is still working during sleep, just working in a different way.

So if our brain is already struggling a little bit, then it can struggle with the architecture of sleep, with being able to do sleep well. It may not be able to do memory consolidation or waste clearance or adenosine clearance. Or we're just not able to maintain the sleep waves the right way. So we can't synchronize the brain enough to do it well, or we may move in and out of those stages too easily or too slowly.

The Vicious Cycle: Poor Sleep Feeds More Symptoms

This is where we see that slog that so many people go through where it's just like you get up in the morning, you're still exhausted, maybe symptomatic, maybe not, but the battery doesn't run real long that day. You feel exhausted, you feel tired, things don't — it's hard to get momentum on it, right?

If we get that slow-wave sleep deficit, we get less of that nice delta wave. And remember what happens during that time? That's when the synapses are downscaled. Pulls that bioenergy down, consolidates the memory, removes all that junk from the lymphatic system. If that's impaired, we start to lose REM functioning. That ability for cognitive memory consolidation, mood regulation — these things start to get impaired.

You're going to get more neuroinflammation because we're not able to clear. You're going to have more oxidative stress. You're just not able to clean up as well. And then if we've got pain, if we've got anxiety, if we've got problems breathing — these are going to further cause more errors with this. If you're in pain, you're having palpitations, your breathing's weird, your neck is all kinked over so it hurts, or you're choking yourself a little bit — all these things are going to further deteriorate the quality of sleep.

Why Post-Exertional Malaise Is Really a Recovery Problem

If I push it further — we got holidays right, we're trying to have some fun and we overshoot what we're capable of in a day but we're not able to get that restoration on the back end — that's where we see those multiple day slogs that come. People call them post-exertional malaise, but you can kind of see where it's a little more rich to talk about the real stuff underneath it.

I had this conversation today in the office. We were talking about pushing someone a little bit more yesterday and in the course of doing that, we made her tired. And in making her tired, kind of walked the edge of what those symptoms look like. It's part of the game. But the good news on the other side was she was able to sleep through the night and woke up and all of that had recovered. Whereas normally if she'd taken herself to that level, we'd be looking at three days where she'd just be stuck.

When I see that, I get really excited because now we're getting after it — I can push you that way and your body responds with enough restoration to get us back to baseline so we can do it again.

Neuro Rehab as a Sleep Intervention

My perspective on this is I actually think that we should be paying more attention to neuro rehabilitation as a form of sleep intervention. Because these things have a bidirectional and interdependent relationship. If you're good at the neural rehab and you can stimulate the brain in an effective way, it induces plasticity, which then helps consolidation, which then helps sleep improve.

We're not trying to stimulate the whole brain at once and just run you through a load of things. That doesn't work. We want to do things that are specific to pathways that are injured. And when we do that, we take an area that is functioning not as well, but we demand the brain to think of it as a critical pathway and to begin to come in and support it with new resources.

So if we can make it so that brain can do those jobs better, then we start to build it on both ends. I get better at the thing I'm doing during the day — so I get more capacity — but then it also helps me to start bending that capacity toward being able to recover better. And that's where the magic's at.

The Focused Approach: Why Tiny Inputs Have the Biggest Impact

A lot of things that we think about traditionally as rehab are like try to push the whole system. But that is very energy demanding, right? So if I'm walking or running or doing kind of traditional things, I'm using everything. But if instead we say I'm going to take all that energy and focus it on just like how you move your eyes to the left — right, that seems very small — but if that helps us stimulate the part of the brain that's not working as well and I can pull that up, all of a sudden I'm like using my magnifying glass with the sun and just focusing into that one area.

We can control the synaptogenesis in that one area. Focus it there and then build off of that, starting with the areas that aren't working. And by making that little shift and saying, "Let's focus on the areas that needed the most first" — when we do that, what you'll find is you end up doing the tiniest amount of stuff with the biggest amount of impact.

That's the part that's fun to watch, but it's also kind of not as fun to watch because it's boring. Because you're doing just really simple things that really make your brain work for it.

Sleep Medications: A Useful Tool, Not the Whole Answer

So if you think about your sleep medication, the thing that knocks you out is also not really built to do great sleep architecture. It's just more to make you unconscious. The same things that would help you get to sleep aren't necessarily the same things that help your brain really function great during the day, but they probably should be because it's the same system.

Not sleeping is awful. Most people would agree. And so if you can get something that can help you break the cycle on that, relief is real. When I speak, I'm talking about this as the optimal way to think about it. But also, we have plenty of people that are working through with sleep aids. That's totally normal. Everybody who's on sleep aids also knows that they can be useful, but the sleep architecture is not the same. And that's well documented in the research. You're not really sleeping — it's kind of something else, but it's enough to at least prevent the wild stuff from happening.

Matthew Walker wrote a book on sleep that I think is pretty good. One of the quotes he has in there is: you cannot replace the benefits that your brain and body get from sleep with anything other than sleep. There's no medication you can take instead of sleep. There's no exercise you can do instead of sleep. The only way to recover from sleep deprivation is to sleep. That's why it is so, so stinking important.

The Bottom Line

Sleep is the fundamental engine of neuro-restoration, plasticity, and toxin clearance. Addressing sleep architecture is a primary part of therapeutic targets in neurological recovery. It's not just a side project. It's part of how we think about the restoration of neural pathways during wakefulness that then influence neural pathways during sleep — and this beautiful holistic body that we have. It's no wonder that when it is able to function better during our normal tasks of the day, it also helps us sleep better at night.

So sleep — turns out it's great. Turns out strong brain, better at sleep.

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