To sleep, perchance to dream…


ResearchBlogging.org
Have you ever had a series of nights with broken sleep? It seems OK on the first night, and most of us can function adequately that next day, but if it goes on, and on, and on – and on… then life starts to take on a negative hue and even little things can feel pretty daunting.

Over the weekend I took a trip to see my son, necessitating two nights so-called sleep in a hotel.  It was a nice hotel, lovely bed, warm, and I even had wonderful pillows – but not a lot of sleep because right outside the window was a main road, down which noisy party-goers and rowdy cars and trucks and buses passed all night.  To top it off, there was a crash outside my window with sirens and flashy lights and – well, you get my point!  Not so bad on the first night, but the second and my patience was wearing a little thin.

For many of the people attending for pain management, sleep disruption is ‘normal’.  Part of the problem is the nature of our sleep architecture – periodic changes in the sleep ‘depth’ leave us a bit vulnerable to waking (such as just before or just after a period of REM sleep), and if there is something like a noise, discomfort (full bladder, painful hip, stuffy nose), then we’re much more likely to rouse fully and be aware of waking up when normally we’d roll over and go back to sleep without knowing that we’d been awake.  Part of the problem too, is that for many people with chronic pain, medications (and/or the use of alcohol or marijuana) can increase our drowsiness, making it easy to fall asleep – but not so easy to remain asleep, or to fall back to sleep once they’ve woken up.

We also know that after a few days without good sleep, we can get cranky.  Life doesn’t seem quite so nice!  Sleep disruption is often a feature of mood disorders and anxiety – and many people with persistent pain have co-occurring mood problems.  Combine low mood with poor sleep – and we know the outcome is increased pain on the days following a poor night’s sleep, and after a day of increased pain, the following night’s sleep is often poor as well.

Helping people develop good sleep patterns is a common part of pain management.  Simple sleep hygiene habits (like this) are often included in pain management programmes.  Relaxation strategies are also often part of pain management.  Including relaxation training in sleep management can help people counter their increased arousal levels if they wake during the night, but can also help people fall asleep in the first place, making the use of hypnotics, alcohol and other drugs less necessary.  A recent study of CBT treatment for insomnia found that it is highly effective, even when delivered in a group format.

The role of negative mood in the sleep-pain relationship is not well understood. The relationship between sleep disturbance and negative mood is well-established, with sleep problems being listed as a symptom of both major depression and anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders-IV, Text Revision.

Increased negative mood has been found to increase perceptions of a period after pain. (O’Brien, Waxenburg, Atcheson et al. 2010)

The study I’ve cited today found some interesting features – people with different types of pain have different types of sleep problem.  People with fibromyalgia and low back pain had poorer sleep than those with facial pain.  The differences weren’t so much in terms of type of sleep disturbance, but in terms of how much sleep was lost.

Poor sleep lead directly to lower mood, and to higher pain, but when low mood was used as a mediator, it was found to mediate the relationship between sleep and pain.

What this means for us as clinicians is that it may be helpful to address both sleep hygiene – and low mood – and that either or both may influence pain.

This study found that negative mood may influence pain intensity via poor sleep – meaning that if negative affect is addressed, it may have an influence on pain indirectly.

It also suggests that as therapists we may need to move beyond simple sleep hygiene practices. ‘ Sleep restriction temporarily reduces an individual’s time in bed to be consistent with the amount of time that they report actually sleeping (typically via sleep diaries). This reduces the amount of time spent awake in bed and may also result in individuals’ developing a
temporary sleep debt, which primes homeostatic mechanisms to promote sleep.’

More on this strategy later this week!

O’Brien EM, Waxenberg LB, Atchison JW, Gremillion HA, Staud RM, McCrae CS, & Robinson ME (2010). Negative mood mediates the effect of poor sleep on pain among chronic pain patients. The Clinical journal of pain, 26 (4), 310-9 PMID: 20393266

Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10:45–56.

6 comments

  1. Hi Bronnie.

    I am very much enjoying your blog!

    I was wondering about two things regarding this blog post:

    1) Studies have shown that damaged nerves can become extremely sensitive to increased levels of acid or low pH and that this kind of sensitivity can trigger pain. At the NOI courses it has been speculated that night pain in fact could be due to this type of nerve sensitivity where you have a pain condition of neurogenic origin (as seen with many chronic pain patients). Many of my patients with these characteristica have been describing how getting up, sitting in a relieving position or walking around during the night can decrease the pain. That certainly fits with this theory.
    My point is this: Can “disturbing” the sleep by getting up before (if that’s at all possible…) the pain is produced by increasing the pH-levels thereby decreasing the pH-sensitivity in the nerve and thereby contribute to decreasing parts of the central sensitivity? (I know that central sensitivity is much more complex than this)
    What is your clinical experience and have you come across data that has explored this?

    2) Do you in the clinic distinguish between sleep disturbance due to pain (where the pain awakens the patient) and disturbance due to “unrest” or something else besides pain? And would the “sleep approach” eventually be different?

    It should be fair to say that I am not treating chronic pain patients on a regular basis – but are in contact with at least one or two per day. I am working in a unit with postsurgical rehabilitation (especially shoulder/arm and back problems). I have for many years been interested in the approaches to chronic pain. In the unit we see a lot of patients on the “cusp of chronicity” with some of these postsurgical conditions. Naturally our focus is to decrease this potential for developing postsurgical chronic pain…

    A long comment but the sleep disturbance issue has been on my mind for a long time…

    Kind regards
    Adam Bjerre
    Physiotherapist
    Denmark

    1. Hi Adam
      I’m not sure I can answer all of your questions – but thanks for posting them, it’ll give me some topics to review!
      As far as I am aware, the studies on sleep disturbance suggest that although patients report that it’s the pain that wakes them, they tend to coincide with the normal variations in sleep depth/architecture. The experience of ‘pain waking me’ could be an artifact of increased awareness of pain during these periods – but I’m not entirely certain of this.
      Regarding getting up ‘before’ the pain increases – clinically, people report that it’s the process of falling asleep in the first place that is difficult when pain levels are high (particularly with neuropathic pain). Given that we do know that disturbed sleep is strongly associated with higher pain levels the following day, I’m not sure that getting up in a planned way would be all that helpful. My approach has been to help people become ‘mindful’ of their pain while falling asleep (ie aware of in a nonjudgemental way), reduce their overall physiological arousal, and learn to fall asleep even with the pain present. While being ‘mindfully aware’ of the pain, people are also inclined to be mindfully aware of other sensations – sounds, contact of the body against the bed or sheets or bedclothes, sensation of warm air being breathed out and cooler air being breathed in – and all of these things can be helpful for getting pain into perspective and minimising the distress component of having pain (& therefore waking up fully).
      Clinically I do a full sleep assessment, reviewing as many factors that could contribute not only to the initial development of a sleep problem, but also those factors that could be maintaining it as a problem. In terms of managing poor sleep, I don’t distinguish between cause or maintaining factors, but systematically address sleep hygiene first, then cognitions/rumination, relaxation/physiological self regulation, and finally when necessary, incorporate sleep restriction into the mix. And yes, we do use tricyclic antidepressant medications as one of the options for extending the sleep duration at times.
      More on this tomorrow though!
      cheers
      Bronnie

      1. Adam, here’s one paper that supports my contention that awakenings are, in themselves, not good for people with chronic pain – a small study, but quite interesting.
        The effects of sleep deprivation on pain inhibition and spontaneous pain in women.
        SMITH MT, EDWARDS RR, MCCANN UD, HAYTHORNTHWAITE JA.
        Sleep 2007;30(4):494-505.

  2. Thank you for your quick and thorough reply, Bronnie. I can see your point (and the study results) about the awakenings. The suggestions about pain and the normal variations in sleep architechture is new to me and quite interesting.

    Thank you for posting such practical information on this topic. It’s definitely an important area of intervention in postsurgical rehabilitation as well as in any pain state.

    1. Hi Adam
      You’re so right – this is an important area for post-surgical rehabilitation! In the case of acute pain (ie within the 2 – 4 month period), especially where adequate pain relief through medication is available, one option would be to ensure that people are using their medication well, with a view to consolidating their sleep. For example, a person I saw recently uses tramadol, and had been waking around 3.00 am to take her third dose of the day, then taking another dose at around 7.00 am, and the second dose about 8.00pm. I suggested maintaining the morning dose at that time, taking her second dose a little earlier, maybe around 7.00pm, and her third dose at around 11.00pm. It was slow release tramadol, and a side effect is sleepiness, so by having the two doses a little closer together, she has adequate cover for the night, while not making her wake up to take the third dose.
      A similar response can be found when using tricyclic antidepressants, or neurontin/gabapentin – side effects are often about sleepiness, so if the dose can be timed so sleepiness occurs at night, then it helps to minimise the sleep disturbance – and means the daytime sedation is a little more easily tolerated.
      If it’s acute pain, or sub-acute, then these medications may be tapered off once that pain settles, and sleep disturbance is minimised with the risk of long-term insomnia reduced. If it’s chronic or persistent pain, these medications can be used long-term without as much disruption to the sleep architecture as hypnotics or benzodiazepines.
      Sometimes short term use of something like zopiclone can temporarily reduce distress associated with the thought of not sleeping – and maybe kickstart a slightly more normal sleep pattern – but I’m cautious about this, because it can turn into a ‘safety behaviour’ that reduces the use of active coping.

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