How Does Sleep Effect Pain and How Can I Improve It?

How Does Sleep Effect Pain and How Can I Improve It?

Becca is a 45-year-old woman who works as a CEO of a large tech company. She has spent the last 3 years putting in extra hours to ensure the company is running smoothly and she is performing at her highest potential. With extra hours has come a sacrifice of personal time, including a reduction in physical activity, vacations, homecooked meals, and, of course, sleep. Becca often works late into the night on her computer while cozied up in bed. Over the past 6 months, she has noticed that it is more and more difficult to fall asleep and stay asleep. As a result, she often wakes up feeling tired and has been supplementing with more caffeine throughout the day to cope. She has also noticed more frequent headaches, which means she is using medication on a more regular basis to make sure she is able to get her work done. Unfortunately, Becca is like many of us who sacrifice our own healthy habits to buy more time. But at what expense?

Sleep is one of the most important components of good health as this is when our body rests and resets. Many of us jump to the “I’ll sleep when I’m dead” or “I’ll catch up on sleep later” when we feel pressed for time. But what if I told you that sleep, both time spent sleeping and quality of sleep, don’t just have an effect on how awake we feel but can also have an effect on chronic pain? Good quality sleep can help reduce the risk of persistent pain and allow our body to better manage painful conditions.

Sleep consists of two phases: rapid eye movement (REM) and non-REM sleep. REM is the deeper phase of sleep when dreams occur and, in a typical 7-9 hour night, each phase occurs about 3-5 times. We should wake up feeling refreshed and alert. If you are feeling tired throughout the day, having trouble focusing on tasks, irritable, or difficulty performing daily activities, like driving, you may be experiencing a lack of sleep length or quality.¹

Sleep is considered good if a person is receiving “adequate duration, timing, efficiency, and a level of satisfaction with sleep that leaves a person feeling alert and functional throughout the day”. Typically, it is recommended for adults to receive 7-9 hours per night. It has been found that adults who do not achieve adequate sleep duration or poor-quality sleep are at an increased risk for morbidity and early mortality, including conditions such as cardiovascular disease, obesity, and poor mental health.²

So, I know I need more sleep but how do I do it? Luckily there are some recommendations that are easy to implement and, most importantly, within our control to do so.

A common recommendation is to maintain similar sleep and wake times to promote consistency. However, some flexibility with bedtime is encouraged as it is more beneficial to go to sleep earlier if you are feeling tired.²

In addition to keeping similar sleep and wake times, there are other recommendations to create good habits – commonly called sleep hygiene. These include using the bedroom for sleep and sex only and avoiding stimulation like loud noises and bright lights. This helps the body to associate the bedroom – the bed in particular - with these two activities instead of laying in bed and stimulating the body, such as when we scroll on our phone or watch TV. Additionally, exercising regularly (try to avoid within 4 hours of bedtime), limiting caffeine, tobacco, and alcohol intake 4-6 hours before bed, and limiting fluid intake in the evenings can be helpful to create a good sleep schedule. Other recommendations that can be helpful include, getting out of bed if you can’t fall asleep within 20 minutes and only returning to bed when you feel sleepy.³

Relaxation training has also been found to be beneficial. This includes imagining (and physically creating) a calm environment and progressive muscle relaxation where you tense and relax the muscles from the face to the feet.³

Light can also play a role in our sleep patterns. Natural daylight has been found to be a higher intensity than light typically found inside. Interestingly, each additional hour that is spend outdoors advances sleep by approximately 30 minutes. In other words, if you are having trouble falling asleep at a certain time, getting more sunlight during the day could help you fall asleep sooner as it helps to increase evening fatigue. Sunlight also was found to improve sleep quality and duration.⁴ An easy way to implement this is either devoting part of your lunch break to a daily walk or eating outside.

Melatonin is a hormone many of us are familiar with. You may have even taken melatonin to help fall asleep at one time or another. In fact, taking melatonin has been shown to reduce reports of pain and improve pain inhibition, or “turning off” pain, in persistent pain conditions, such as fibromyalgia. This hormone is at its highest levels at night and has many benefits, including anti-inflammatory, analgesic, and sleep inducing. Keep in mind, it is very easy to turn off, or inhibit, melatonin. Normal fluorescent light is about 10-13 times more powerful than required to inhibit. It is no secret that using electronic devices, such as phones or tablets, before bedtime can reduce your ability to fall asleep and stay asleep.⁵ In other words, try to avoid artificial light when preparing for sleep. Instead, opt for good ole paper books, journaling, or crosswords to help prepare for bedtime.

Sleep and pain have a close relationship. It makes sense that pain can negatively impact our sleep, but did you know that reduced length or quality of sleep can lower our threshold for pain? In fact, reduced sleep duration and poor sleep quality are risk factors for chronic pain development. Furthermore, a lack of sleep, either duration or quality, can increase our sensitivity to painful stimuli and increase “spontaneous pain symptoms”, like a headache.⁵ Studies conducted on healthy individuals have demonstrated that sleep disruption reduces the body’s ability to inhibit, or turn off, pain.⁵

Studies on humans have found that sleep deficiency causes increased cortisol levels and an increase in cortisol in response to stress as compared to those that were not sleep deficient. Prolonged increases in cortisol levels is another large factor in increasing pain levels. One study looked that restricting sleep on weeknights and increasing sleep over the weekend, which many of us do. Healthy individuals experienced an increase in cortisol levels in the morning.⁵ Basically, we are already at a higher likelihood of experiencing increased stress when we don’t get adequate sleep.

Lack of sleep has also been shown to increase inflammatory markers, which are also found in many pain conditions. While more research is needed, there is a relationship between chronic pain, short or disturbed sleep, and low-grade inflammation.⁵

We have the most control over non-medicine approaches to managing sleep, especially as it relates to persistent pain. These approaches include sleep habits, or sleep hygiene, mindfulness, and relaxation techniques. Additionally cognitive behavioral therapy (CBT) has been found to be helpful for those who struggle with insomnia and persistent pain. CBT has multiple components, including sleep hygiene, time in bed restriction, control stimulus, addressing negative cognitions about sleep, and relaxation tools.⁵ Timing when you take certain medications can either help or disrupt sleep. Opioids, antidepressants, cardiovascular drugs like beta-blockers, and corticosteroids, such as cortisone and prednisone, can have a negative impact on sleep, especially if taken towards the end of the day. For example, opioid use for acute and chronic pain reduces REM sleep and increase awakenings and arousal during sleep.⁵

Whether you are experiencing persistent pain conditions or not, sleep is a vital component to health that we often push to wayside. The real question we should be asking is what are we costing ourselves by reducing our sleep? Our bodies are beautifully resilient but how often should we be forgoing good sleep habits at the expense of our current and future health?

If you are working with a healthcare provider, especially to manage persistent pain conditions, they should be discussing the importance of sleep and developing good habits associated with it. If this topic has not been addressed, try implementing some of the strategies above. If you need additional help, don’t be afraid to ask your healthcare provider about additional options or referrals!

Reference List:

1. Sleep deprivation and deficiency. National Heart Lung and Blood Institute. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency. Accessed March 13, 2022.
2. Murawski B, Wade L, Plotnikoff RC, Lubans DR, Duncan MJ. A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders. Sleep Med Rev. 2018;40:160-169. doi:10.1016/j.smrv.2017.12.003
3. Maness DL, Khan M. Nonpharmacologic Management of Chronic Insomnia. Am Fam Physician. 2015;92(12):1058-1064.
4. Blume C, Garbazza C, Spitschan M. Effects of light on human circadian rhythms, sleep and mood. Somnologie (Berl). 2019;23(3):147-156. doi:10.1007/s11818-019-00215-x
5. Haack M, Simpson N, Sethna N, Kaur S, Mullington J. Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. Neuropsychopharmacology. 2020;45(1):205-216. doi:10.1038/s41386-019-0439-z

 Written by: Dr. Jordan Schmidt, DPT, PT