When it comes to pain, sleep is a major factor for many people experiencing chronic pain.
Today, Friday March 14, 2024, is World Sleep Day, a day intended to celebrate sleep and a call to action on important sleep-related issues. The theme for this year’s World Sleep Day is Sleep Equity for Global Health which aligns with our own endeavour for global health, so in support, we are taking the opportunity to share our perspective from the field of pain science. Much of it, thankfully, is becoming much more public knowledge, but we hope you find something new and useful here, too! This post has been extracted from the Sleep Hygiene session in the Explain Pain On-demand course (with Tim Cocks, 2023).
Many people report that they sleep poorly because of pain and/or hurt more because they sleep poorly. Research supports the tight coupling between sleep and pain. Even one night of poor sleep can change how you experience pain the next day. When you don’t sleep enough you are more sensitive, likely to hurt more, be more grumpy, unable to think as clearly or remember well, and perform more poorly in mental and physical activity. However, it’s important to know that improving sleep, even in small amounts, has been shown to improve pain and related symptoms.
Sleep protects our brain by allowing the nervous system to cleanse and remove waste products accumulated throughout the day. The Glymphatic system* is charged with ‘taking out the garbage’, and during sleep, it is one of the only times it is active. So sleep is neuroprotective, and attempting to compensate for lost sleep during the day is ineffective.
(*Named in recognition of its dependence upon glial cells and the similarity of its functions to those of the peripheral lymphatic system.)
If you or your clients struggle with sleep, it’s not all doom and gloom – as we mentioned earlier, even small improvements in sleep can have big influences on our symptoms and cognitive function. There are a number of simple things that can be done to improve sleep; together, these are called good ‘sleep hygiene’. Like movement, diet, and exercise, sleep is definitely worth considering as part of a comprehensive pain management approach.
Strategies for good sleep hygiene
And no, we’re not talking about keeping changing your bed sheets every Sunday!
- Just like babies, adults need a good sleep routine. This includes going to bed and getting up at roughly the same time every day, including weekends, as much as possible. The idea of catching up on sleep on the weekend, say, is not ideal for quality, regular sleep.
- A ‘getting ready for bed’ routine can help and is part of planning for a good sleep.
– Start 30 minutes to one hour before a planned sleep time.
– Turn lights off or down, and avoid bright screens – particularly small ones that are held close to your face.
– Start to relax. If any concerns come to mind during your wind-down, it can help to write them down so that you can deal with them the following day rather than worrying about them all night.
– Try to be in bed 5-10 minutes before you want to go to sleep. The idea is also not to spend a long time in bed before you go to sleep as that can lead to the bed being associated to being awake. Stay out of bed until you intend to go to sleep. - Keep your bedroom dark and minimise any light from phones, outside, or other sources.
- A cool room (about 20 degrees Celsius) is best for most people, but a warm bed if it is cold outside. Stay cool if it is hot. A hot, stuffy room is not conducive to a good night’s sleep.
More basic sleep hygiene strategies:
Avoid smoking or consuming alcohol close to bedtime, as they can lead to interrupted sleep. Alcohol can be particularly problematic, as some people may use it to aid sleep, and although it may feel like it puts you into a deep sleep, paradoxically, this often results in disrupted and poor-quality sleep. Both smoking and alcohol misuse can be significant problems for people experiencing chronic pain, forming part of broader lifestyle practices when it comes to chronic pain.
Similarly, it’s advisable to avoid heavy meals close to bedtime, although a light snack can help if hungry. Ideally, aim to eat at least 2 or 3 hours before your planned bedtime. Bananas are sometimes recommended as an evening snack due to their tryptophan content, a chemical associated with sleep. A triple espresso, however, would not be recommended!
Furthermore, it’s important to steer clear of stimulants such as caffeine and vigorous exercise within a few hours of bed. Caffeine is a biological agent that has a stimulating effect on the central nervous system and can hinder you from winding down. Although exercise is essential, timing is crucial to consider, as vigorous activity releases various chemicals in the body that can disrupt sleep patterns. Physical activity releases all kinds of myokines and chemicals and affects multiple systems in the body.
If you are having trouble sleeping, avoid staying in bed worrying about not being able to get to sleep. It’s okay to get up, but avoid turning on bright lights. Instead, stay in a darkened room and focus on relaxation activities – but not in bed. We want to avoid creating an association between being in bed and being awake. It is okay to read with a little bit of light for a while, or listen to quiet music or a suitable audiobook. After 30 minutes or when you feel sleepy, return to bed, associating being in bed with feelings of tiredness and sleep.
Last, avoid using the bedroom as an office. If you can, aim to associate the bedroom solely with sleep, relaxation, and tiredness. If you undertake work or study in your bedroom, when you are finished and ready to go to sleep, try covering your work things with a cloth – it is like shutting the ‘office door’ and signalling the end of work.
Sleep cycles
It is natural and normal to wake up a few times per night, about every 90 minutes to three hours. We sleep in cycles of different levels of sleep, and at the end of each cycle, we may wake up a little, change position, and go back to sleep. This was probably a good thing to do from an evolutionary perspective to avoid getting eaten! Knowing that a good night’s sleep is not necessarily eight hours of complete unconsciousness can be reassuring.
Georgiev, Ivan. (2020). Neurophysiological control of sleep with special emphasis on melatonin. Trakia Journal of Sciences. 18. 355-376. 10.15547/tjs.2020.04.011.
Many people get very stressed about not getting enough or good sleep. They worry that they wake often in the night (but remember, this is quite normal) or can’t get back to sleep when they naturally wake during the night. Understanding that sleep goes through natural cycles can help. Interestingly, research has shown that if we believe we slept poorly, regardless of the actual quality of sleep, we feel more fatigued and perform worse on cognitive tests. So, finding ways to positively frame the quality of your sleep, may be a little hack to try!
The recommended amount of sleep varies across age groups. Adults should aim for six to eight hours of sleep per night, while teenagers and young adults may require up to nine hours. Older adults over 65 may need less sleep, but individual needs vary across the lifespan.
Clinical application
These strategies can be implemented one at a time in an order that the patient thinks might help. You might take on a few at a time and monitor the effects over several weeks or months. These options offer a buffet of choices, crucially involving the individual you are working with. It can take time for them to have an effect; it might be just one night, or it may be changing routines over weeks and months.
At a basic level, if you are working with a person experiencing chronic pain, then simply screening for sleep by asking about it is a minimum requirement. Ask a few questions about their sleep; there are some sleep questionnaires out there that you could use to start the conversation such as the Leeds Sleep Evaluation Questionnaire (LSEQ). If sleep emerges as a significant problem, you could start with some simple techniques from this array of options we’ve discussed. Or if you think something really significant may be in play, then consider referring them back to their GP for further assessment. There are doctors, psychologists and other therapists who specialise in sleep problems.
Basic relaxation techniques to practice just before sleep can help. Progressive muscle relaxation techniques, meditative or slow breathing techniques. You could suggest taking a moment to consider the things they’re grateful for and to take those thoughts as a focus in their mind as they’re winding down and relaxing their bodies. Needless to say, tailor it to the individual.
‘Don’t have time to sleep?’ Not sleeping will make you much less effective/productive during the day and will often do the opposite of what you are trying to do – you won’t get MORE out of the day, you will in fact get a whole lot less.
Despite there being many negative impacts from sleep issues, it is also important that we walk that fine line of not increasing worries and concerns around sleep. Finding ways to focus on one or two small things may be big steps in someone’s return to better sleep.
Final thoughts
- Healthy lifestyle matters are touchy or emotive – consider the skills and empathy to address them. People experiencing chronic pain often feel stigmatised, invalidated, and feel like no one believes them. If they are approached without empathy, they can often feel like they’re being attacked. That’s not your intention by any means, but that’s how people can feel at times, so approach with care.
- Consider complexity – singular approaches might not be as effective as considering the whole person and their context: consider: movement/exercise AND sleep AND diet AND stress management as part of a comprehensive program. Where do we start? Maybe we should ask? Some people may not see the link between these things and their pain, but that’s where the clinician’s educational approaches and discussions can be important. Giving someone a sense of choice, agency, or control can also be integral for long-term change. If you’re feeling stuck, complexity reminds us that there are multiple ways to influence the system. If the way we are trying to facilitate change with someone isn’t helping, then there will be another way – something else to consider.
- Education providing a powerful ‘why’ is probably essential. Most people know, in a sense, KNOW that a healthy lifestyle is important, but if they’re not doing it, then there are significant barriers getting in the way. Education and exploration of those barriers can be important. You can help them shift to making it a priority – this takes some skill, communication, empathy, and kindness, but it’s worth your time. You can make sense of it together.
- Be kind, patient and compassionate! Patient, because changes are not going to happen overnight. It takes time to see the benefit, and as a therapist, you can model that patience and set realistic expectations and time frames. You’ll likely be dealing with months of change rather than days or weeks before there’s a significant benefit.
Further reading
Babiloni_2020_Sleep and pain- recent insights, mechanisms, and future directions in the investigation of this relationship
Baranwal_2023_Sleep physiology, pathophysiology, and sleep hygiene
Draganich_2014_sleep fatigue beliefs
Thank you for reading, if you have one take away may it be to make sleep a priority!
Comments are welcome below.
– The Noigroup Team
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