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Importance of Sleep in Pain Control

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Sleep is a basic human function that plays an important role in our brain function and overall health.  Unfortunately, up to 70 million people in the US have a chronic sleep disorder that impacts daily functioning and health1. Good sleep is a combination of how long we sleep (quantity) and how well we sleep (quality). The American Academy of Sleep Medicine has recommended that adults sleep seven or more hours per night on a regular basis to promote optimal health2. The short and long term consequences of poor sleep include stress, anxiety, mood disturbances, trouble focusing, cardiovascular disease, obesity, type 2 diabetes, cancer and even death in extreme cases1. Many studies are starting to shed light on the role of good sleep in pain management and ways to approach this simple yet daunting task.

Lets Start with the Basics…The Anatomy of Sleep 101

Sleep can be broken down into two main parts – REM (rapid eye movement) and NREM (non-rapid eye movement). REM starts about 90 minutes after we fall asleep. The stages of REM sleep get longer and longer with the final one being about 1 hour. Dreams happen during REM sleep. The body also goes through many changes in REM sleep including faster breathing, increased brain activity, and muscle relaxation. NREM sleep is made up of 4 stages; stages 3 and 4 are the deep sleep stages. These stages are very important because the body repairs and regenerates tissues and strengthens the immune system during this time. As we get older we get less NREM sleep3. Both REM and NREM sleep are important in resetting our bodies in order to feel refreshed. When we get either decreased number of total hours or choppy sleep, the body is unable to go through the appropriate restorative stages.

Next up…. The Chemistry of Sleep

Bad sleep (either quantity or quality) can result in a low-grade inflammatory response due to increased levels of chemicals such as interleukin 6, prostaglandin E2 and nitric oxide4. Inflammation, as we know, is not good for the body or the mind. Other neurotransmitters in the brain such as dopamine and serotonin have been shown to help regulate sleep as well as pain. Although the exact mechanism by which these neurotransmitters affect our sleep is complex, their imbalance may play a role in sleep dysfunction in patient with chronic pain4.

The Vicious Cycle of Bad Sleep and Worsening Pain

On paper it makes sense…. when we are in a lot of pain, it is hard to sleep, and when we don’t sleep well, we have more pain. Scientific data supports this catch-22. In March 2019, a study by Krause found that acute sleep deprivation amplifies the pain signal in the human somatosensory cortex (as seen on functional MRI) and lowers the threshold for what the body/brain considers to be painful5. Compared to chronic pain patients without sleep issues, those with bad sleep reported more severe pain, greater levels of anxiety/depression and impairments in physical functioning6 .

Lets Talk Action! What Can Be Done?

Treating poor sleep is as difficult as treating chronic pain. There is no simple answer or one size fits all option. The seemingly simple solution of taking a “sleeping pill” does not always end up being as simple as it seems. Many of these medications have side effects that are not easily tolerated, and many have interactions with other drugs one might be taking. In addition, pain medications including opioids also impact the sleep-wake cycle by decreasing the total amount of REM and deep sleep thereby worsening sleep while attempting to treat pain4.

Cognitive Behavioral Therapy for Insomnia (CBT-I) 7 has been shown to have a positive and lasting impact on sleep and pain management. Some important aspects include:

1). Stimulus control – go to bed early, use bed/bedroom only for sleep and sex, get out of bed when cannot fall asleep within 15-20 min, avoid naps.

2). Relaxation training – used to reduce sleep interfering somatic or cognitive tension at or around bedtime.

3).  Biofeedback – using visual or auditory feedback to help increase control over biologic responses (ex heart rate, muscle tension).

4). Cognitive therapy –  identifying unhelpful and challenging thoughts about sleep and replacing them with helpful substitutes through discussion. Stressing over bad sleep makes sleep itself worse!

5). Sleep Hygiene – quiet/clean bedroom, dietary changes (avoid alcohol and caffeine), behavioral changes (exercise can improve sleep leading to better mood and a healthy level of fatigue at end of day to promote good sleep).

If you are suffering from chronic pain and sleep dysfunction, speak with your healthcare provider about resources that would be beneficial for you. Please also contact us at Desert Spine and Sports Physicians to set up an appointment where we offer comprehensive, evidence-based, non-surgical care for your musculoskeletal needs.

 

References

  1. Medic G et al., Short and long term health consequences of sleep disruption. Nat Sci Sleep. 2017;9: 151-161.
  2. https://www-uptodate-com.mwu.idm.oclc.org/contents/insufficient-sleep-definition-epidemiology-and-adverse-outcomes?search=sleep&topicRef=7710&source=see_link
  3. https://my.clevelandclinic.org/health/articles/12148-sleep-basics
  4. Nijs J et al., Sleep disturbances in chronic pain: neurobiology, assessment, and treatment in physical therapist practice. Physical Therapy. Volume 98, Issue 5, May 2018, Pages 325-335.
  5. Krause A et al., The pain of sleep loss: a brain characterization in humans. Journal of Neuroscience. 20 March 2019, 39 (12) 2291-2300.
  6. Tang N, Insomnia co-occurring with chronic pain: clinical features, interaction, assessments and possible interventions. Rev Pain. 2008 Sep; 2(1) 2-7.
  7. Smith M et al., How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive- behavioral clinical trials literature. Sleep Medicine Reviews. Volume 8, Issue 2, April 2004, Pages 119-132.