sleep

Combating Sleep Problems Associated With Chronic Pain

/ Thomas Cohn, MD

sleep pain chronicSleep for individuals with chronic pain is often a major struggle. Unfortunately, just like the cause of pain itself, it is a difficult and multifaceted problem with different issues contributing to sleep struggles. Pain and discomfort at night are the leading complaints, but often it is more complicated and usually not a simple issue to solve.

Underlying medical problems may also be contributing to sleep disturbances, and not addressing these may prevent adequate solutions. Addressing sleep problems often requires intervention from multiple specialists.

The Importance Of Sleep Hygiene

Sleep problems can range from simple to complex problems. Starting with the simple issues is always important. First is trying to discover what are the difficulties with sleep and what habits and patterns for sleep occur with a person. Sleep hygiene is one of the leading areas of problems. One of the most common problems is the consumption of caffeine or similar stimulants during the day. Most people are sensitive to caffeine, and it is found in many drinks, especially various sodas and teas. Drinking these after the lunch hour for many can affect sleep. The use of alcoholic beverages can also interrupt sleep, initially it may make one tired, but as it wears off, the body awakens and one may be running to the bathroom.

Sleep hygiene also includes the habits one has in the bedroom. Currently, the most common problem is screen time including computers, tablets, television and phones prior to sleep. Watching a screen tends to activate the brain and wake a person up, and the color spectrum produced with lots of blue light is also awakening. Turning off the all the screens one hour before bedtime is advised. The bedroom should be reserved for sleep. Doing work in bed and spending time in bed not sleeping gives the brain the wrong signals to stay awake. Lastly, most people sleep better in a cool room, being to warm leads to restlessness.

Your Mattress and Sleep

The most common question that is asked to me is should I get a new bed and what bed should I get? Anyone who has shopped for a bed knows this is an expansive proposition. Before buying a new bed, try to get everything right in the bedroom first, from the room temperature to the sleep hygiene. If the bed is old, first try a mattress topper with 3-4 inches of quality memory foam. A good topper is far cheaper then a full mattress and may be perfect solution. A new bed is only needed if your mattress is ancient and beyond salvage.  

Since beds can be extremely expensive, start with determining your budget and then look at your options from memory foam mattresses to adjustable air bladder types like the Sleep Number bed. The mail order memory foam mattresses are often extremely affordable, comfortable and are reported to be a good quality. Everyone has a different preference for a bed, but if it is rock hard, it will not provide uniform body support and probably cause more pain. A bed that is too soft will probably also be uncomfortable and not provide adequate support to the body. The first recommendation would be try a memory foam type mattress for a new bed. If your budget is less constrained, the ability to change a bed’s hardness and support with an air bladder type bed is wonderful. Adjustable bed frames that can raise the head or feet is a further luxury.

The last issue with chronic pain and sleep is once you have optimized the sleep environment, what else can be done? The first concern is to see if there another medical concern preventing sleep. A sleep specialist often best evaluates these issues, and those who are neurologists often have the broadest understanding of all the issues. They can address problems from restless legs, sleep apnea to interrupted sleep by pain. They can be extremely helpful in determining the best medication routine for improving sleep. If a safe simple solution is not working, a sleep specialist is extremely important in determining the path forward.

Sleep and Caffeine May Play Key Role In Controlling Chronic Pain

/ Thomas Cohn, MD

sleep caffeineNew research out of Boston suggests that sleep and caffeine may play integral roles in controlling chronic pain flareups.

It’s probably not a huge surprise that sleep is beneficial for controlling chronic pain, as we’ve talked about the restorative benefits of sleep on our blog many times before, but the part about caffeine is interesting. Here’s what the researchers had to say.

Benefits of Sleep and Caffeine

For their study, researchers looked at the effects of sleep (or lack thereof) and caffeine on mice and their pain sensitivity. Researchers began by tracking normal sleep cycles and measuring brain activity, then they began to disrupt this healthy sleep cycle by giving mice toys and activities that entertained them and kept them awake (much like Netflix or our iPads do for humans).

“Mice love nesting, so when they started to get sleepy (as seen by their EEG/EMG pattern) we would give them nesting materials like a wipe or cotton ball,” says Dr. Alban Latremoliere, PhD and pain expert at Boston Children’s Hospital. “Rodents also like chewing, so we introduced a lot of activities based around chewing, for example, having to chew through something to get to a cotton ball.”

Researchers kept mice awake for up to 12 hours in one night or for six hours five nights in a row. They examined that fatigue, stress and pain sensitivity all increased during this time.

“We found that five consecutive days of moderate sleep deprivation can significantly exacerbate pain sensitivity over time in otherwise healthy mice,” says Dr. Chloe Alexandre, a sleep physiologist.

Caffeine’s Role

According to researchers, common painkillers did not help mice combat pain, and morphine was less effective in sleep-deprived mice, meaning chronic pain patients who are tired may have to up their morphine dose in order for it to be effective. However, researchers found that caffeine helped to block pain sensitivity.

This led researchers to conclude that a good night’s sleep combined with caffeine during the day (along with other good habits like regular exercise and a healthy diet) may be more effective for managing chronic pain than simply relaying on analgesic medications.

“Many patients with chronic pain suffer from poor sleep and daytime fatigue, and some pain medications themselves can contribute to these co-morbidities,” Dr. Kiran Maski, M.D. at Boston Children’s hospital who studies sleep disorders. “This study suggests a novel approach to pain management that would be relatively easy to implement in clinical care.”

Sleep, Insomnia, and Pain

/ Thomas Cohn, MD

pain and insomniaDifficulty sleeping is a common problem with patients in pain.  Good quality sleep throughout the night often reduces the intensity and perception of pain.  There are many causes and not a single solution for poor sleep.  Pain in the neck and low back regions can cause discomfort within a short amount of time while lying down.  Chronic pain can also cause anxiety and depression and that can contribute to sleep issues.  To make matters even more complicated, the medications used to control pain may have side effects that impair sleep. Patients with chronic pain may also have other medical conditions that cause difficulty with sleep.

Sleep Postitions

Treating sleep problems in patients with pain is often quite complex. The first step in treating sleep-related pain is to make sure the patient has good positioning of the body with regards to the spine in a neutral position.  For neck pain this would be using a pillow that supports the head without having the neck bent if lying on the side, or a thin pillow with a slight neck roll if lying on the back.  Low back patients need pillows to support their position if lying on the side between the knees and sometimes supporting the stomach or against the back.  Having multiple pillows to maintain a good position is normal.  If lying on the back, having a pillow under the knees improves the low back position reducing stress on those muscles.  A bed that accommodates and maintains natural curvatures of the body, such as a memory foam mattress or an adjustable air bed also may be helpful to reduce stress and pain on either the neck or low back.

Pain, Anxiety, and Sleep

Pain itself can cause sleep difficulties related to anxiety and depression.  The centers in the brain that interpret pain signals and those associated with anxiety and depression are in the same regions.  Often as one develops chronic pain, anxiety also occurs and contributes to sleep problems.  Not treating this problem adequately can worsen the pain since these areas of the brain tend to interact.  Often anxiety has been treated with benzodiazepines like:

  • Valium
  • Ativan
  • Xanax
  • clonazepam

These medicines induce the first phases of sleep but not the deeper sleep that is needed.  Anxiety in pain patients is often a symptom of depression, and is not well treated with the above medications.  Using antidepressants actually treats the chemical imbalances that occur and with the right medications the symptoms improve as well as the sleep.

In pain patients, recent studies show that sleep problems are often mixed with significant concern about not being able to sleep.  Patients tend to concentrate on not being able to sleep and this then becomes the reality.  More drugs with side affects is typically not the best solution.  More effective treatment is the use of cognitive behavioral therapy (CBT).  This is a psychological method of retraining the brain to think in a constructive fashion and this reduces the anxiety about sleep and anxiety.  Studies have found the use of CBT to be equally or more effective in managing sleep problems in pain patients than the use of medications.

Traditional pain medications like opioids also have negative effects on sleep.  These drugs tend to reduce deep sleep and increase the shallow phase 2 sleep.  Deep sleep phases are the periods that are necessary to feel rested.  The more potent opioids also have a tendency to increase both obstructive sleep apnea and central sleep apnea. Both decrease oxygen levels in the body and lead to frequent awakening.  Sleep apnea will markedly decrease deep sleep and the quality of sleep.

New Sleep Medications

Ease of falling asleep, being able to stay asleep, and having deep restorative sleep measure good quality sleep.  With good sleep, one should feel well rested and have less pain.  As noted above, one of the best management techniques for sleep is using cognitive behavioral therapy.  Medications are starting to get better.  The newer sleep medications over the last ten years like Ambien and Lunesta help induce sleep, they do not keep one asleep and may cause hangover and odd behaviors like sleep walking.  Melatonin type medications also induce sleep, can be used safely long-term, but do not maintain prolonged deeper sleep. The newest medication is Belsomra and this appears to be inducing and maintaining sleep.  One old time medication, doxepin at very low doses also seems to have similar properties.

If one has pain and sleep difficulties, it is important to discuss the problem with your pain physician.  A trial of simple solutions, either CBT or melatonin type medications is reasonable.  If the sleep problems are ongoing, being evaluated by sleep specialists and having a sleep study done is beneficial.  Sleep apnea is common in pain patients and treating these problems is essential in managing sleep.  Ongoing sleep problems may require a combination of solutions since multiple factors are probably present.  Like managing pain, sleep is complex and often difficult to find a solution to improve the situation.

5 Tips for Sleeping Through Pain

/ Thomas Cohn, MD

sleep through painWhen you’re in pain as the result of an injury or other condition, oftentimes the best remedy is to get plenty of rest and sleep. But sleeping through pain is easier said than done. Rolling over onto a painful back, leg, or arm can wake you up (and keep you up) in the middle of the night. More pain equals less sleep, and less sleep slows your recovery. It’s a vicious (dare I say painful) cycle.

But there are a steps you can take to help sleep soundly through the pain. Here are a few tips:

  1. Take your pain relief medications as directed, and right before bed if possible.
  2. Reduce your caffeine intake. Coffee, soda, and energy drinks are jam packed with caffeine. They are designed to keep you awake and alert. This is great if you need a pick me up at work, but not when you’re trying to sleep. If you can’t cut out the caffeine completely, try to only drink it in the morning.
  3. Cut down alcohol consumption. Many people find that a “nightcap” helps put them to sleep. While it’s true that alcohol can induce drowsiness, the sugars in alcohol are more likely to wake your body up later in the night.
  4. Get into a sleep cycle. Try to go to bed and wake up at the same times every day. This will help your body get into an internal rhythm or groove.
  5. Relax and avoid physical activity before bed. Exercising is a great way to reduce your pain, but exercising too late in the evening can keep you up and make it difficult to fall asleep.

Whether you’re dealing with chronic pain from an illness, or acute pain following an injury or surgery, getting a good night’s sleep is essential for your overall health. Follow these tips and you’ll be off to dreamland in no time.