The relationship between Sleep and Chronic pain

Sleep problems and chronic pain seem to go hand in hand. Frequently people with chronic pain find it difficult to fall asleep, or sleep is often disrupted with long night awakenings. Even if you get a good amount of sleep, you can still feel very tired in the morning as the quality of sleep is often poor. Because of this, it is common for people to want to address sleep as part of pain management.

Having a bad night’s sleep can make you feel more pain sensitive. Pain and sleep are closely linked and impact each other. There is a reciprocal relationship where pain during the day affects the quality of that night’s sleep and poor quality sleep increases pain levels the next day.

In fact the latest findings point to sleep effecting pain levels greater than the other way round. So it is important to try and give yourself the best chance of having as good sleep as possible.

Some sleep facts

It is helpful to understand some basic concepts about sleep before we look at what we can do to improve it.

• To drop off to sleep our nervous system has to calm down. If you have chronic pain, you have a much more active nervous system. This can interfere with how quickly you fall asleep and how deep a sleep you get.

• Know what good sleep looks like. Most people assume that a good night’s sleep involves a steady drop into deep sleep, staying in that deep sleep for most of the night and then gradually moving up into a lighter sleep before you wake. Healthy sleep actually looks quite different from that and instead comes in waves during the night – see the image below.

  

There are a number of stages of sleep we cycle through:

• We start with stages 1 and 2 which are lighter stages of sleep.
• Then we go down into deeper sleep in stages 3 and 4 sometimes called slow wave sleep.
• We move back up to lighter sleep and then into rapid eye movement or REM sleep. This is where we dream.
• This cycle gets repeated a number of times throughout the night, with more time spent in deep sleep at the beginning of the night and more time spent in lighter stages and dreaming towards the morning.

Notice that after most of the REM stages, we wake up. It is normal to wake multiple times a night. Most people will roll over and go straight back to sleep without even realising it.  When you are in pain, you can wake and notice your pain. This results in an increase in the activity in your nervous system that then has to calm down all over again to fall back to sleep. If you learn how to fall asleep more quickly initially, many of these same strategies will also help you to fall back to sleep once you wake during the night.

Pain affects sleep, but a lot of other factors can either improve or impair sleep too. These are things that you may have more control over and if addressed, can help your sleep.

How can I improve my sleep?

To help improve your sleeping experience with pain try utilise some of sleeping with pain recommendations.

1. Routine

• Get up at the same time each morning regardless of the sleep you had the night before.
• Go to bed roughly around the same time each night
• Spend half an hour (a very active person may need longer than this) before bed, doing the same things in the same order each night, e.g. get things ready for the next day, have a shower, brush teeth, get into pyjamas then read a book. This helps the body learn to expect sleep and prepare for it.

2. Only go to bed when you’re sleepy

Your sleep goes in waves throughout the night. Your energy levels also go in waves throughout the day. It is important to go to bed when the energy level is in a dip.

• Look for signs of sleepiness

3. Make the association between “bed” and “sleep” really strong

Your body learns to make associations all the time. We notice that our mouths salivate when we smell our favourite food cooking. We have learnt that soon after smelling food, we will get to eat it. We want to build up the association between bed and sleep, NOT bed and other activities, or bed and stressing about not sleeping, or bed and pain.

• Only use the bed for sleeping (and sex) ie. no reading books, watching tv, resting. Find somewhere other than the bedroom to rest during the day.
• That also means no tossing and turning in bed feeling frustrated about being awake.
• If it has been more than 20 mins (roughly) and you have not fallen asleep, get out of bed and do a quiet (non-stimulating) activity, until you feel sleepy and try again.

4. Sleep hygiene

This simply means, managing those things that you do during the day that can affect sleep.

◘ Diet

• avoid heavy, fatty or sugary foods before bed
• avoid caffeine, coffee, coke and chocolate 4 hrs before bed
• have some milk – it is sleep promoting

◘ Exercise

• Even low levels of exercise are beneficial to sleep
• Don’t exercise within 2-3 hours before going to bed, as it will increase the heart rate and body temperature making it harder to sleep

◘ Light

The greater the difference between day time light and evening darkness, the more “melatonin” the body produces (the hormone that promotes sleep). To increase melatonin:

• Reduce light in the bedroom
• Increase sun light exposure during the day
• Noise: Ensure a quiet environment
• Temperature: A warm shower in the evening is helpful as it will increase the body surface temperature initially, followed by cooling of the core body temperature. This promotes sleep.

5. Avoid napping

Having a nap during the day will impact the quality of sleep during the next night, making it lighter and more easily disrupted. This increases the desire for a nap the next day, creating a vicious cycle.

• Only have a nap during the day as a one off, for a special reason (not routinely).
• If you have to nap, take a short nap in the morning when you will have a lighter sleep and it will have less of an impact on the next night’s sleep.

Special Tips:

1. Remove the clock: When you worry about not sleeping, this increases the activity of your nervous system and will make it more difficult for you to fall asleep. One of the things that can increase our anxiety about not sleeping, is watching the clock. Consider removing the clock from your bedroom. If you need an alarm to wake you, turn the clock around so you can’t actually see the time.

2. Acceptance: When you can’t sleep, it can also be helpful to remember that this is a natural side effect to pain: fighting against it makes things worse. Accepting you have some sleep difficulties will reduce the distress that you may otherwise feel.

3. Mindfulness: You may find writing down your thoughts and assure yourself that you will address them in the morning. Often our thoughts chase themselves in circles and writing helps to clarify and structure our thinking processes which can help to come up with solutions to our problems.

What about medications and sleep?

Medication can assist in helping you to improve your sleep but are not recommended as a standalone treatment. Many sleep medications are indicated for short term use only as your body builds up tolerance to them. If you have a breathing related sleep problems such as obstructive or central sleep apnoea, see your doctor.

Professional help

Getting you back into the life that you want involves both managing the impact of your pain and improving your sleep. Some of the techniques used can be difficult to implement. If this is the case, it is good to seek professional help.

Zanskar Health offers cognitive behavioral psychologists who can help with sleep management and can also assist with underlying mood and anxiety issues as well. Get in touch if you want help to break the sleep - pain cycle.

Learn More About Zanskar Health for Chronic Pain

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Medical Review: This article is written by Dr Nishtha Mittal (Senior Health Content Editor at Zanskar Health) and has been medically reviewed by Dr Rashi Goel (Senior Physiotherapist at Zanskar Health). This article and its contents are provided for educational and informational purposes only and do not constitute medical advice or professional services specific to you or your medical condition.

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