Sleep is tough for those with chronic pain. This guide takes you through how sleep affects pain, and how to sleep well despite the pain, plus at the end of this post, you can enjoy our free sleep meditations.
Sleep is vital for all of us: it gives our minds the chance to process memories and information, as well as giving our bodies time to rest and recuperate. When we are deprived of sleep, it can increase our risk for a range of health issues.
Sleep is a hard thing to achieve when you live with chronic pain, and that’s putting it lightly! This is such a common problem that it tends to be known as ‘painsomnia’ within the chronic pain community.
Even when we do manage to get a night’s sleep, it’s often non-restorative, which means that we don’t feel the benefits of being asleep. It’s common to wake up feeling just as tired as when you first went to bed! Unfortunately, these sleep issues can feed into the chronic pain cycle.
This study from the Journal of Pain states that “Sleep complaints are present in 67-88% of chronic pain disorders and at least 50% of individuals with insomnia the most commonly diagnosed disorder of sleep impairment suffer from chronic pain”.
So why and how are chronic pain and sleep so deeply linked? Let’s take a look at the science behind the connection, and what you can do about it.
How Chronic Pain Disrupts Sleep
Pain itself - The experience of being in pain itself understandably makes it difficult to sleep. It’s tough to get comfortable enough to drift off to sleep. Pain can quite easily wake you up in the night even after you do get to sleep, particularly if you experience shooting pains or a sudden surge in pain levels during the night.
Allodynia - Allodynia is a symptom of some pain conditions which causes pain even in reaction to things that wouldn’t usually cause pain, such as a light touch. This can make it difficult to get comfortable at night and can be very irritating. For example, the feeling of tight pajamas or a scratchy duvet cover could cause pain.
Reduced activity levels - Many people with chronic pain (especially those who are not receiving treatment) may have reduced activity levels. This means that even if they experience fatigue, their body isn’t properly ‘tired out’ and ready to sleep.
Disrupted routine - Often when we are unable to sleep, our routine can become disrupted. You may start to go to bed much later than you normally would, and even sleep in. This can disrupt your body clock, making it harder to get to sleep at a ‘normal’ time.
Overactive nervous system - To get to sleep, your nervous system needs to ‘calm down’ so that you can relax. Those with chronic pain often have an overactive nervous system, so may find this much harder.
Medication side effects - Some of the medications which may be prescribed for chronic pain can disrupt sleep. Opioids in particular disrupt the cycle of sleep, often preventing the individual from reaching important stages of sleep, as this study explains.
Some antidepressants and anticonvulsants which are prescribed to pain patients can also prevent the individual from accessing specific stages of the sleep cycle which are vital.
Stress and worry about not sleeping - Stress and pain create a vicious cycle, one causing and worsening the other. This leads to many pain patients being in a chronic state of stress, meaning that their bodies and minds are almost constantly in a state of high alert. This can prevent full relaxation and therefore affect sleep.
Once you’ve been finding it tough to sleep, it’s common to become very aware of the fact that you might not sleep at night. This can lead to catastrophizing (thinking of the worst scenario) and rumination (overthinking). The more aware and worried you become about not being able to sleep, the harder it can become to find sleep. In addition, rumination and catastrophizing are proven to worsen pain levels.
Lack of distractions - Many pain patients, myself included, use distraction as a tool to stop them from focusing on their symptoms. Even if you aren’t actively using distraction as a coping technique when you lie in bed at night all of the things that keep your mind busy during the day are gone. We’re in silence and our minds are left to wander. This can result in pain and other symptoms being amplified because we’re so aware of them.
An ongoing cycle - Once you have experienced one night of poor sleep, it can become more difficult to get to sleep the next night. Lack of sleep can increase fatigue and other symptoms during the day. A cycle of frustration and anxiety can build around the experience of getting to sleep.
The National Sleep Foundation states that “If someone experiences poor sleep due to pain one night, he or she is likely to experience more problems the next night and so on.”
How Poor Sleep Affects Chronic Pain
Increased response to pain - Lack of sleep can make us more susceptible to pain and heighten our chronic pain levels. This 2019 study explains that “Experiments in humans establish that total, partial, and selective sleep deprivation increase pain, including a lowering of pain thresholds.” This means that hyperalgesia (increased sensitivity to pain) can be caused by sleep disturbance. This effect can accumulate over time, worsening and perpetuating chronic pain.
Recent studies have also indicated that how much sleep you get, and how restful that sleep is, actually correlates with how severe pain intensity is among other factors. This study from the Journal of Pain discovered that: “Greater sleep disturbance was associated with greater pain intensity, worse function, greater emotional distress, lower positive affect, and higher levels of catastrophizing.“
Many of the areas of our brain which control our sleep also play a vital part in controlling our pain levels. The area of our brain which is responsible for our ‘sleep’ and ‘awake’ states, has an overlapping function of pain inhibition. This means that they can easily influence one another.
The central nervous system can play a big part in the connection between insomnia and chronic pain. This article from the Arthritis Foundation and Dr. Lee's Ph.D. (Director of the Alabama Research Institute on Aging) explains that “studies show CNS pathways (the spinal cord and brain) that regulate pain may be abnormal in people who are not sleeping well.”
The hormone and neurotransmitter dopamine has many vital jobs, including helping with the regulation of sleep, and pain and keeping our mood stable. It’s thought that an imbalance of dopamine could result in insomnia and higher pain levels.
Increased inflammation - Lack of sleep can reduce the immune system, particularly over an extended period. This can make you more vulnerable to other illnesses. Not only is this bad for general health, but when our immune system is disturbed, it can increase the inflammatory response within the body. Over time this increased inflammation can have significant negative effects.
When your inflammatory response becomes prolonged, it can damage cells and organs as well as cause and increase chronic pain levels. The immune response can stimulate nerve endings and therefore make them more sensitive to pain (contributing to central sensitization).
Impacted mental health - A lack of sleep, particularly if it happens regularly, can significantly impact your mental health and cause cognitive disturbances. We know that due to the mind-body connection, our mental health markedly influences our chronic pain symptoms.
When our mood is low, we’re less likely to keep up with effective pain management strategies, engage in treatment, and practice self-care. In turn, we are more likely to engage in maladaptive (meaning unhelpful) behaviors: this can be detrimental to our pain levels.
Lack of sleep can also disturb our cognitive processing, making us more likely to perceive our pain negatively. Negative pain perceptions feedback to the brain that it ‘should’ continue producing pain messages, therefore contributing to the chronic pain cycle.
When our cognitive processes are disturbed, it becomes more difficult to distract ourselves from our pain and focus on productive ways to manage it. This study found that “insufficient sleep weakens the ability to attend to and disengage oneself from painful stimuli so that the net outcome is an exaggerated pain sensation.”
How To Sleep Well
That can all sound scary and alarming. But there is hope!
The good thing about sleep correlating with pain levels is that if you can get restful sleep, pain levels can be reduced! One of the studies we mentioned earlier from 2019 states that, “even modest improvements in sleep quality have the potential to reduce subjectively significant pain.”
As tough as getting sleep can be, there are ways that you can increase the chances of a restful night’s sleep.
Set a ‘bedtime’ and ‘awake time’ - To get your body clock back on track (and keep it on track) it’s vital to have a sleep routine. You should get up around the same time each day and go to bed at the same time each night, whether you have slept well or not.
Remember that this needs to be achievable for you so that you can stick to it. You don’t have to get up at the crack of dawn or go to bed early. What’s important is to have a routine that will be sustainable. Choose times that you feel are realistic for you and your lifestyle.
Avoid napping during the day - Although it’s easier said than done, it’s important to try and avoid napping during the day. If this isn’t possible due to fatigue, try to limit the amount and length of naps you take. This will help your body and mind to feel ready to sleep at night.
When I first started to put a sleep routine in place, I found it tough. I was napping every day, going to bed late, and getting up late. However, I took my time and gradually reduced my naps. As hard as it was, it made a huge difference. Now I rarely nap during the day unless my symptoms are flaring.
Make your bedroom a sanctuary - Your bedroom needs to be a place within which you can relax and unwind. It needs to be a safe, comfortable space, like your own sanctuary. You can do this in several ways.
A great place to start is to make sure your bed is comfortable. If your bed isn’t supportive and comfortable, you could choose to buy a new bed or mattress (if resources allow). If not, you could add a mattress topper to increase your levels of comfort.
You could add more pillows and blankets to create a cozy atmosphere. My mother-in-law bought me a weighted blanket which promotes a sense of relaxation and is very comforting. I would recommend one as a way to increase a feeling of calm.
Ensure that your bedroom is as dark as possible at night. When we’re in a dark environment our bodies release melatonin, the hormone which helps us to sleep. You could use blackout curtains, or wear an eye mask for example. You could also introduce dimmed lights while you’re in your bedroom before you sleep.
It’s important to reduce any noise as much as possible. You could wear headphones to listen to relaxing music, an audiobook, or meditation as you drift off to sleep. If you find that you’re disturbed easily, you could consider wearing earplugs while you sleep.
The temperature in your bedroom is so essential for restful sleep. Being too hot or cold can wake you up. You could introduce a fan or a heater to get your bedroom to the right temperature. Take your time to figure out what temperature feels right to you. In general, a cooler room leads to more restful sleep.
Stimulus control - Controlling what stimuli are present within your bedroom sanctuary is vital. You must associate the bedroom environment with relaxation only. It’s a good idea to avoid TV in the bedroom for example. Any music you listen to in the bedroom should be relaxing in nature. You should try not to eat, take phone calls, or do other daytime activities in your bedroom. The aim of this is to ensure that your brain makes the connection between your bedroom and sleep only.
Changing what you eat and drink - Some simple alterations to your diet can be effective in helping prepare the body for sleep. The National Sleep Foundation recommends stopping or reducing caffeine and alcohol intake, especially in the evening and at night. It’s also advisable to stop or reduce nicotine: these are all stimulants and can make getting to sleep more difficult.
When you eat and drink is just as important as what you consume. Going to bed feeling hungry, or even overly full, can make you feel less comfortable in bed. Eat a balanced meal so you will have time to digest it properly before bed. You could even have a light snack before bed to ensure you’re not left hungry.
It’s also important not to drink too much before bed, especially if you find that you are needing to get up in the night to go to the toilet. This can take a process of trial and error as we’re all different, so be kind to yourself as you figure out what works for you.
Schedule your medications effectively - Any change in your medications should always be guided by your doctor, however, it’s worth asking if you could change your medication schedule slightly to promote better sleep. If you take medications that cause drowsiness, it can be great to take them at night to make the most of the side effects to aid sleep.
If possible, it’s a good idea to avoid taking medications that make you drowsy early in the day, as this can make you feel more inclined to rest and be less active.
If you take painkillers or other medications to control your pain, taking them a little while before you go to bed can help to control your pain, making you more likely to sleep.
Being active during the day - It’s so important to be active during the day and to exercise. Not only does this improve your general health and reduce chronic pain symptoms, but it also wears your body and mind out healthily, aiding in restful sleep. It’s important not to exercise too close to bedtime because this can make you feel more awake, so do your exercise during the day or in the evening for the best results.
Have a ‘wind-down’ routine - Around 30 minutes to an hour before bed, you should implement a ‘wind-down’ routine to help your body and mind get into a relaxed state. It’s a great idea to do things that help you to feel ready for bed, for example, taking a bath or shower; doing your skincare routine if you have one (something I enjoy at bedtime); turning off the TV and reading a book, or changing into your pajamas.
Do your best to manage your pain before bed, to try to reduce your symptoms as much as possible ready for sleep. This could involve taking any pain medications, using heat and cold, or using a self-massaging device (these can be relaxing and ease discomfort).
Mindfulness - Mindfulness can help you to reduce stress and it promotes a sense of deep relaxation which can improve your sleep quality significantly. Practicing mindfulness helps you to let go of worries and focus on the present. This can be very useful in reducing anxiety around sleeping. Mindfulness can also relax the muscles to reduce pain and prepare you for sleep: this is usually done through progressive muscle relaxation (PMR).
This 2018 study tested the use of mindfulness to improve the sleep of fibromyalgia patients, and discovered positive, long-term results: “Individuals in the mindfulness group demonstrated significant improvements across all outcome measures and that the intervention effects were maintained at a 3-month follow-up assessment.”
You could practice mindfulness a little while before bed, or even while in bed to help you to drift off to sleep.
Cognitive behavioral therapy (CBT) - CBT can help you to face the fears and stress you may have built up around not being able to sleep and aid with relaxation techniques. Typically, CBT is combined with other therapy methods to bring the best results for patients struggling with insomnia. This article explains that “Cognitive-behavioral therapies (CBT) for pain and insomnia usually include relaxation training augmented by biofeedback, coping skills training, cognitive therapy, increasing activity levels, and goal setting.”
Avoid ‘time checking’ during the night - We’ve all been there. When you can’t sleep, it can become a habit to look at the clock. You begin to think, “If I fall asleep now, I’ll get 5 hours of sleep”, or “There’s no point going to sleep now, there’s only 3 hours until I have to get up”! This often winds us up more, increasing stress and restlessness. Try to avoid time-checking if you can’t sleep. Instead, you could practice some relaxation techniques.
If you do need to get up, Harvard Medical School advises going into a quiet room with a dim light and reading a book or listening to some relaxing music. This is more productive than doing something stimulating like watching the TV or looking at social media, as this could make you feel more awake.
Something I’ve found helpful is changing the way I think about not being able to sleep so that it feels less stressful. If I’m lying awake, instead of thinking negatively about not being able to sleep, I actively think that even though I’m not asleep right now, lying calmly in bed is still helping my body and mind to relax and get some rest. When I took the pressure off and reduced the stress around the experience, in time this helped me to drift back off to sleep much more easily.
Medication options - If you are struggling, you could talk to your doctor about the possibility of sleeping tablets. However, these tablets can cause drowsiness the following day, which could contribute to fatigue. Doctors tend to only prescribe sleeping tablets when all other options have been explored. They would typically be used for a short time, rather than as a long-term solution.
Seeking professional help - You could reach out for help from a sleep specialist. You could ask your doctor about your options. A sleep clinic may be suggested. These are clinics you stay at overnight, perhaps for several nights. The professionals there can help to evaluate your sleep problem properly and provide appropriate guidance to improve your sleep.
Treating your chronic pain - There are lots of highly effective treatments to help you reduce and overcome your chronic pain. By dealing with the cause of your lack of sleep, you will in turn be able to achieve more restful sleep. Take your time to do some research, seek guidance and figure out which chronic pain treatments could work for you. You can access treatments through your doctor, privately or online.
Precision Pain Care and Rehabilitation has two convenient locations in Richmond Hill – Queens and New Hyde Park – Long Island. Call the Queens office at (718) 215-1888, or (516) 419-4480 for the Long Island office, to arrange an appointment with our Interventional Pain Management Specialist, Dr. Jeffrey Chacko.