August 23, 2022

The Relationship Between Sleep and Chronic Pain

It’s true – the relationship between sleep and pain is complicated. But if you’re struggling with chronic pain, getting a good night’s sleep is essential.

If you have osteoarthritis (OA), chances are you may also struggle with getting a good night’s sleep on a consistent basis. The relationship between chronic pain and sleep is a tricky and complex one. The truth of the matter is that poor sleep can make us more vulnerable to pain, and pain can affect sleep – it’s a vicious cycle that can be difficult to escape.

Research suggests that 67-88% of people with chronic pain disorders experience sleep complaints. Inversely, at least 50% of people with insomnia (one of the most commonly diagnosed sleep disturbances) also suffer from chronic pain [1]. If you’re struggling with the stressful poor sleep-chronic pain cycle, know that you’re not alone. And luckily, there are many paths you can explore to help both pain management and sleep quality.

Before we dive into some remedies and strategies you can try out, let’s get a basic understanding of sleep and pain under our belts.

What is Pain? 

At its simplest, pain is a signal from our brains telling us that something is wrong and in need of our attention. As an injury occurs, like breaking a bone or touching a hot stove, signals travel from the injury to the brain and trigger a flurry of activity that prompts us to withdraw from the painful stimuli and seek treatment. In other words, pain is basically a giant red flag.

There are two types of pain: acute and chronic. Acute pain usually flares up after an injury, and fades as the injury heals. In some cases though, the pain doesn’t go away or, alternatively, seems to come out of nowhere. This type of pain is called chronic pain.

What is Chronic Pain?

Chronic pain is pain that persists longer than 12 weeks. With acute pain, nerves at the sight of the injury fire signals that trigger a pain response in our brains that activates resources to promote healing, such as inflammation or seeking treatment. With chronic pain, our nerves continue firing these pain signals, even when there isn’t a clear cause.

Common Causes of Chronic Pain

Chronic pain occurs for many reasons. Pain can set in due to an injury, then persist long after the injury has healed. Pain can also result from complex, progressive conditions like osteoarthritis, where widespread and chronic inflammation can increase sensitivity to nerve endings and worsen pain. Other times, chronic pain may pop up seemingly without rhyme or reason, and can have more to do with our mental health.

Commonly reported sources of chronic pain include [2]:

  • Headaches

  • Lower back pain

  • Cancer pain

  • Arthritis pain

  • Fibromyalgia

  • Neurogenic pain (pain from nerve damage to the central nervous system or peripheral nerves)

  • Psychogenic pain (pain with no clear cause or underlying tissue or nerve damage)

When treating chronic pain, most physicians wll first look at the underlying cause. Although this is a critical first step, chronic pain often evolves into its own condition involving psychological, emotional, and physical factors that may require separate attention.

Why Does Sleep Matter?

Sleep is a restorative process that gives our body downtime to recover from the rigors of the day. Getting the recommended 7-9 hours of high-quality sleep contributes to our long term wellness, impacting every aspect of life from mood and mental performance to energy levels, physical health, and yes – pain conditions. 

Stages of Sleep

There are four main stages of sleep, labeled as N1, N2, N3 and REM. All are critical to wellbeing, but the bulk of the beneficial effects of sleep are associated with Stage 3 (N3) and REM [3]. 

Stage 1 Sleep

Stage 1 (N1) is generally associated with dozing off and is very brief, lasting up to five minutes. During this stage, our brain waves begin to slow and muscles may twitch as the body relaxes.

Stage 2 Sleep

During stage 2 (N2) sleep, our bodies continue relaxing. Heart rate and breathing slows, body temperature drops, and muscles relax. Brain wave activity continues slowing with intermittent bursts of activity that help prevent outside stimuli from waking us up. This stage lasts about 25 minutes during our first sleep cycle, but grows longer during later cycles through the night.

Stage 3 Sleep 

Stage 3 (N3) is the first stage of deep sleep and is widely regarded as the stage most vital to restorative sleep, facilitating tissue repair, and bodily recovery. Some evidence suggests N3 sleep is beneficial for creativity, memory, and insightful thinking. During this stage, brain waves slow even further, producing delta waves that give N3 sleep the name slow-wave sleep.

REM Sleep

During REM sleep, brain activity nears waking levels, even as our body experiences atonia, a temporary paralysis of the muscles that prevents us from hurting ourselves in our sleep. REM sleep is associated with vivid dreams and is thought to significantly impact cognitive functions like memory, creativity, and learning. It often takes about 90 minutes of sleep for our brains and bodies to relax and experience REM.

Getting adequate sleep in each stage is essential to maintaining a strong and healthy system. But for people with ongoing sleep issues, accessing those restorative stages of deep N3 sleep and REM sleep can be challenging and leave you in a chronic state of fatigue.

What are Sleep Disturbances?

Sleep disturbances are disorders or conditions that interrupt or prevent you from getting uninterrupted, restorative, high-quality sleep. 

The Center for Disease Control reports that roughly 70 million Americans struggle with chronic sleep problems [4], so if you struggle with sleep, know that you’re not alone. To date, over 100 different sleep disorders have been identified (like insomnia and sleep apnea), and can be organized into four main categories [5]: 

  • Trouble falling asleep

  • Difficulty staying asleep

  • Imbalances and issues with the circadian rhythm that prevent uninterrupted quality sleep

  • A tendency towards unusual behaviors that disrupt sleep

The Relationship between Sleep and Chronic Pain

Research has found that interrupting slow-wave sleep results in “unrefreshing sleep, diffuse musculoskeletal pain, tenderness, and fatigue in normal healthy subjects.” [6] And unfortunately, chronic pain often worsens these effects of sleep. Whether from an overlapping sleep disorder, or from joint pain and stiffness that’s triggered by movement during sleep, people with chronic pain often experience frequent nighttime wakings and less restful overall sleep. Pain can also impact sleep positions and how much we truly rest in slow-wave sleep in a given night.

Other studies suggest sleep may be a more reliable and stronger predictor of pain than pain is of causing sleep disturbances [7]. Regardless of which has the stronger influence, there’s no arguing amongst experts that high quality sleep can positively impact our experience of pain, so let’s dive into some techniques you can try at home!

How to Improve Sleep and Chronic Pain

As explored above, the research suggests that getting a good night’s sleep can significantly impact our experience with chronic pain. If you’re struggling with poor sleep that’s exacerbating your pain, here are a few approaches that could help.

Sleep Medications

Most sleep medications are intended for short-term use and to be taken in tandem with behavioral therapies or good sleep practices. Commonly prescribed sleep medications include [8]:

  • Anti-Parkinson drugs (dopamine agonists) (prescribed for restless leg syndrome and periodic limb movement disorder)

  • Benzodiazepines (prescribed for sleep disturbances including sleep terrors, sleepwalking, nightmare disorder and sleep paralysis)

  • Non-benzodiazepine hypnotics (prescribed for short-term insomnia)

  • Melatonin receptor stimulator (prescribed for insomnia)

  • Anticonvulsants (prescribed for nocturnal eating syndrome, periodic limb movement disorder, restless leg syndrome, and insomnia related to bipolar disorder.)

  • Antinarcoleptics (prescribed to promote wakefulness during the day for those with narcolepsy or sleep apnea)

  • Antidepressants or anti-anxiety medication (used to promote drowsiness)

  • Orexin receptor antagonists (prescribed to promote wakefulness during the day)

It needs to be noted that sleep medicine can interact with pain medication, so people with chronic pain may not be eligible for sleep meds. Pain medication can also cause its own sleep issues. Additionally, sleep medication prescribed for people with chronic pain aren’t always effective. The American Academy of Pain Medicine found prescription pain-killing drug treatments only help 58% of people with chronic pain [9].

Melatonin

Melatonin is a naturally occurring hormone that helps regulate our sleep-wake cycle. Melatonin production increases with darkness, helping to promote restful sleep. Although the majority of melatonin’s benefits have been found for delayed sleep-wake phase disorder and jet lag, there is some evidence suggesting it may help with other sleep issues [10]. Most people actually take a higher dose than is recommended — aim for doses between 0.3-0.5mg to get melatonin’s optimal effects.

Psychological Techniques

Physical pain can contribute to emotional pain, which in turn can make it difficult to get quality sleep and heighten our experience of pain. For this reason, it can be helpful to explore psychological techniques that can serve to soothe us during the day and calm our minds as we try to drift off to sleep.

Some popular options include:

  • Meditation

  • Breathing exercises

  • Cognitive behavioral therapy

Sleep Hygiene

Sleep hygiene refers to practices and routines that help facilitate sleep and set you up for a deeply restorative slumber.

  • Avoid screens (Or use a blue light filter like F.lux that adjusts screens towards more calmly and sleep-stimulating red and yellow lights.)

  • Use your bed ONLY for sleep and intimacy.

  • If you’re not asleep or tired after 30 minutes, get out of bed and do something else, preferably a different relaxing activity.

  • Develop an evening ritual that helps you relax. This could include meditation, aromatherapy, listening to relaxing music, soaking in a hot bath, drinking warm milk or non-caffeinated tea, and more.

  • Get up at the same time every day. It can be tough to escape the “sleep when you can” mentality, but a consistent wake-up time can help your body get used to falling asleep at the same time each day as well.

  • Avoid naps during the day.

  • Avoid caffeine, alcohol, and nicotine before bed.

  • Regular exercise can promote tiredness and help you sleep, just be sure to schedule it earlier in the day (and not within hours of going to bed.)

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