SLEEP HYGIENE FOR CHRONIC PAIN


Whether it is the inability to fall asleep, to stay asleep for the recommended seven to eight hours, or waking up too early (for example, 4 a.m. versus 6 a.m.), chronic pain can cause sleep problems in a number of ways. Lack of sleep can worsen pain, and result in a cyclic escalation of depression and pain during the day. Sleep is vital to controlling pain for anyone who has pain on a chronic basis. Because chronic pain and sleep disorders are closely linked they must be treated together. Back pain regularly causes sleep problems, which can then delay healing or even make a back problem worse.

It has been estimated that nearly two-thirds of those with chronic pain suffer from a sleep disorder. For those people, there are a variety of sleep aids available to address sleep problems and make it more likely that they will have more restful nights. Typical sleep aids include:

  • Adopting habits (sleep hygiene) that facilitate sleep, and condition the body to fall to sleep.

  • Using psychological techniques that can develop the mental state needed to fall to sleep and stay asleep.

  • Constructing the right sleep environment to minimize pain, including the right pillow(s) and mattress.

  • Using appropriate over-the-counter or prescription medication.

Sleep Hygiene (first step)


Eliminating behaviors known to interfere with sleep and adopting actions that can signal the body that it is time to prepare for sleep are both critical aspects of combating sleep problems.

Avoid the following:

  • Having caffeinated drinks like coffee, tea or soda within six hours of bedtime, which are stimulants.

  • Exercising within four to six hours of bedtime, because it can energize the body and require time to recuperate. However, there are some conditions that respond better to mild exercise before sleeping.

  • Eating too much, or eating spicy foods prior to bedtime.

  • Using alcohol or nicotine, both of which can disrupt sleep.

In contrast, activities that alleviate pain and prepare the body for sleep can lead to higher-quality rest. These include:

  • Vigorously exercising early in the day, which will help lead to deep sleep at night.

  • Taking a warm bath in the evening, which can relax muscles.

  • Stretching for t3-5 minutes before bedtime can loosen joints and help relax stiff muscles.

  • Drinking a warm, non-caffeinated beverage about an hour before bedtime, such as warm milk, or herbal tea.

  • Going to bed and waking up at the same time everyday; reinforces the "sleep cycle".

  • Create a dark and quiet environment; consider a sound machine.

  • Avoid naps during the day.

  • Avoid reading or lounging in bed; create a sleep environment only for sleep.

Psychological Approaches

"Mind over matter” can help patients override or re-balance pain signals with more pleasant, sleep-inducing thoughts. A few techniques that have proven successful are:

  • Self-Hypnosis, which can help a patient associate certain actions with sleep (such as turning off lights or closing doors and drapes).

  • Visualization of something peaceful or relaxing, like clouds in a night sky, can be a good transition from the work day to more restful nighttime.

  • Meditation or other relaxation practices that incorporate deep breathing and aim to free or compartmentalize feelings of stress and in the body.

  • “Forced worrying”. Several hours before bedtime create a brief period of time (15 minutes or so) to write down worries. Then leave the room where you wrote down the worries, and if worrying recurs, remind yourself that you will have time to think about these worries tomorrow.

 

Creating an environment conducive to sleep


A comfortable bed and inviting bedroom can also be effective sleep aids, and can make a difference in the quality of sleep experienced. The following can make for a restful environment:

  • Body or neck pillows to provide support; pillows under the knee, or between the knees if a patient sleeps on his side, can relieve stress on painful areas.

  • A high quality mattress that is both comfortable and provides adequate support. May consider trying different mattress or beds.

  • Appropriate levels of light and sound. Light can be minimized using black-out curtains, and noise diminished by a solid wood door between rooms. Alternatively, gentle music can provide a soothing background to drift off.

 

Medications for Sleep
If behavior and environment changes have not proven to be sufficient sleep aids, patients should discuss with their physician whether over-the-counter or prescription drugs should be used for pain control and/or sleep assistance.

 

  • Pain medication. These include analgesics (e.g. Tylenol), and non-steroidal anti-inflammatory agents (NSAIDs), such as aspirin, ibuprofen (e.g., Advil), naproxen (e.g., Aleve), and the new COX-2 inhibitors. Stronger prescription pain relievers include muscle relaxants (generally used to treat muscle spasms) and antidepressants and anticonvulsants, which are sometimes used to treat nerve pain. Narcotic pain relievers are available but are generally used after surgery to treat intense pain.

  • Sleep medications. These can include over-the-counter drugs that have a sedating effect, like antihistamines, or combination pain reliever and sleep aids, such as Tylenol PM. Hypnotics are stronger prescription medications that promote sleep, and fall into two classes: the benzodiazepines (e.g., Halcion or Restoril), and the non-benzodiazepines, benzodiazepine receptor agonists (e.g. Ambien or Lunesta). A new type of sleep medication, marketed as Rozerem, was introduced to consumers in 2006 and works by targeting the melatonin receptors in the brain that control the sleep-wake cycle.

  • Antidepressants (Antidepressant medications). Sometimes sleep disturbance in pain patients can be a result of untreated clinical depression. Other symptoms of clinical depression include appetite disturbance, decreased energy and motivation, lowered sex drive, crying spells, anxiety, lack of enjoyment, or problems with concentration and memory. If you are experiencing these symptoms discuss the possibility of an antidepressants with your physician. Sleep disturbance should improve as the depression improves, beginning one to three weeks after starting antidepressants.

While all these medications have been approved by the FDA, it should be noted that all have side effects which patients should consider, including the highly addictive nature of some pain medications and sleep aids. Also, combinations of pain and sleep medications may interact poorly, so caution should be exercised when using both types of drugs.