Sleep – Posts from 2010

Sleep is so important for wellbeing (ask any young parent!), and yet many people with chronic pain have really poor and unrefreshing sleep, and very poor sleep habits.  Some pain conditions show changes to the quality of the sleep stages (such as fibromyalgia for example), to the point where these changes can almost be diagnostic, while many people with chronic pain also have low mood in which sleep disruption is a common feature.

I’ve written about sleep several times over the past year, and today I provide links to some of these posts for your education and enjoyment.

Sleep problems in chronic pain and what helps – Pain can be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep.

Thinking about sleep – or not – CBT responses to common thoughts and beliefs when introducing sleep management.

Oh, to sleep – CBT for insomnia in chronic pain – Cognitive-behavioral therapy for insomnia (CBT-I) is a well-established approach for helping people return to a refreshing sleep pattern, this study describes research about four strategies.

If you’re not asleep, get out of bed! – Sleep restriction as a strategy for optimising time in bed actually asleep.

To sleep, perchance to dream – different types of pain problem can link to different types of sleep problem.

Don’t forget that an effective strategy for helping with sleep onset is deep relaxation, and mindful attention to sensations such as the contact of the body on the bed, the breath in and out, and attending to each body part without necessarily changing the position can all help to ease into sleep.  I’ve also used ambient sound recordings – for me the sound of the sea is particularly relaxing – and recordings like this can mask street noises provided that the recording can remain on all night.  It’s better to learn to send yourself to sleep without external aids like recordings where possible, because if you wake during the night and haven’t learned the art of going to sleep by yourself, you’ll need those same aids at that point in time too.

Working with thoughts: habits take time to change

If only there was a magic wand. I could make millions out of a ‘quick fix’ to changing habits! Unfortunately my magic wand is red and glittery – and plastic. I call it my ‘self management’ wand because it reminds me that self management is no quick fix, and a good deal of the work we need to do is about helping people recognize unhelpful thoughts and behaviors that might work in the short term, but not so in the long term. Changing patterns for sleeping well despite chronic pain is no different – what might have been going on for years isn’t likely to change overnight.

Some of the thoughts that people have when embarking on cognitive behavioral therapy for insomnia can be quite unhelpful. One woman I worked with became despondent and eventually gave up because she got very irritable and felt too exhausted to carry on with sleep restriction, and told me her husband didn’t want her to stay up until she was sleepy as we had planned ‘because he can’t stand me being grumpy all the time’. She’d been having problems with sleep for four years, and we had worked on a sleep program for three weeks.

Today I’d respond a bit differently: when someone says ‘Oh but I just can’t do this’ I’d spend more time exploring how long the sleep problem had been going, and discuss the short term vs long term gains. If the problem with sleep has been going on for a long time, the difficulty from sleep restriction over a fortnight or so in order to improve sleep over the long term might be worth it. It’s worth using something like a decisional balance chart, or ‘pro’s and con’s’ chart that draws up the good and not so good of each habit that influences sleep. Habits like going to bed early after a few nights of poor sleep might help the immediate fatigue – but the probability of waking during the night is increased, which in turn maintains the poor sleep pattern. Forgoing the sleep program because of irritability or fatigue might keep the peace at home in the short term – but maintains the erratic sleep pattern that can interfere with good relationships in the long term.

If someone is raising the concern that they won’t be able to cope with excessive sleepiness during the initial phases of sleep modification, it’s worth considering introducing change over a Friday to Monday – that way the excessive sleepiness is confined to the weekend. In really challenging cases, the person might be able to take a week off work or a holiday, and time the program to commence during this time.

There is good reason not to change the planned program too much because of the person’s fears of being ‘too sleepy’. This is because one aspect of a sleep program is to evaluate the person’s fears that not being able to sleep will lead to ‘catastrophic’ consequences. By not challenging this belief, a tiny bit of doubt can remain in the person’s mind that the program won’t work in the real world – or when the person isn’t seeing the clinician.

Many people start a program but don’t manage to carry it out. This seems especially common with regard to that horrid part of sleep management: getting out of bed in the middle of the night if you’re not asleep. You’ll probably know these thoughts: ‘oh it’s so nice in bed, it’s too hard to get out of bed’; ‘maybe if I stay in bed I’ll just fall asleep, if I get out of bed I’ll just wake up properly and then I’ll never get any sleep’; ‘I’ll wake my partner if I get out of bed so I’ll just lie here and rest’.

Something worth considering is to explain to the person that at night some of the parts of the brain that help to evaluate and judge and monitor impulse control (frontal lobes) are affected both by fatigue – and by circadian rhythms. In other words, it is actually harder to reason logically at night, leading to more difficulty following through with difficult actions. By letting the person know that ‘it’s not your fault, it’s your brain letting you down’, it can help the person understand why it can be more difficult and as a result, help them apply some additional ‘push’ to overcome that tendency.

Working with catastrophic thoughts
One of the maintaining factors in insomnia is worry, or rumination. Now while there are some subtle differences between these, I’m going to treat them as the same for the purposes of this part of my discussion.

It’s common to think that being a ‘worrier’ causes insomnia – and to a certain extent, especially in the initial stages of the problem, that’s true. It’s very common for people with pain to be worried about a lot of things in the early stages of the pain problem, and what better time to think about these things than when in bed? Well, actually it’s not an especially good time, particularly in the middle of the night because it helps to maintain alertness, and more importantly, because of the problems with logical reasoning (see above). What typically happens is that thoughts just run around and around without coming to any resolution.

Once insomnia is established, self-perpetuating thoughts can maintain it. Things like ‘I’ll never get any sleep tonight’, or ‘tomorrow is going to be a write-off’. By working through these thoughts, perhaps using a whiteboard and listing the thoughts and working through to the ‘worst case scenario’ (in other words, following the catastrophic chain of thinking, we can work through to the underlying fears that have real emotional sting. Then we need to do some reality testing. Reality testing in this case involves making some estimates of how likely it is that each of these thoughts will come true. Using a percentage, each thought that has been jotted down is given a rating in terms of how probable it is that the fear will come true.

The next step is to work out how often each of the catastrophes actually DO come true. For example, if the thought is ‘I’ll never get to sleep tonight’ – how often has that actually come true? How often does the person actually get not a single moment of sleep at night? Probably the answer will be near to nil. The next catastrophe can be discussed the same way – how likely is it that tomorrow is a write-off? It helps to define what ‘write-off’ actually looks like: is it falling asleep at work? Is it forgetting to do a specific task? The question to ask is ‘how many times have you slept so badly that you fell asleep at work?’ Again, the answer is probably next to nil, but might be once or twice.

Then it’s important to point out the mismatch between the feared probability and the actual occurrence of the catastrophe.

You can do some maths here if you like: work out the number of nights in a year where the person has had insomnia, multiple this by the probability they give of ‘never sleeping’, and arrive at a number. Then work out the number of days where the person has actually fallen asleep and multiply this by the number of nights of insomnia. This quite clearly points out the disparity between what the person is worrying about – and the likelihood that it actually happens.

It helps at this point to remind the person again that at night, their logical thinking goes awry and so it makes it harder to think clearly, so some helpful phrases could be brought in to counter that fear. Something like ‘I won’t sleep at all tonight’ could be countered with ‘I probably will sleep at least a bit, and even if I do have a bad night’s sleep, it’s not very likely that I’ll fall asleep at work, so I can deal with it just fine.’

By using information from the person, and working through the maths, it helps to reduce the emotional reasoning that can otherwise influence behavior.

Let me know what you think – worth trying this approach for other catastrophic thoughts?

Thinking about sleep – or not…

It’s 3.00 in the morning.  You haven’t slept since you got into bed at 11.00, and the last time you had a full night’s sleep was some months ago.  Every morning you wake up feeling as though you haven’t really slept yet – and every day is just the same.

I can understand why people who have sleeping problems (and yes, I’m one of them!) often have quite strong reactions when they’re introduced to some of the concepts that are most successful for restoring a normal sleep pattern.  While the basic principles of sleep hygiene are well-known and reasonably simple, putting them – and other more challenging strategies in place – can be quite a difficult process.

It’s what goes through a person’s mind that makes it difficult – so today I’ve focused on some of the common thoughts that people can have, and how we as clinicians can respond to them.  These responses are primarily from a cognitive behavioural approach, with some ACT thrown in for good measure.

Introducing baseline
The most common reaction to ‘Now I’m going to ask you to record your sleep habits over the next week or so, please don’t change anything you’re currently doing’ is ‘Can’t you tell me just one thing I can do to help my sleep now?’ Your response needs to be along the lines of helping the person understand why you’re spending this first week or so recording current sleep habits.
The reason? So that you and the person have a really good understanding of the various factors impacting upon his or her sleep – so that you can work with the person to change unhelpful patterns. You can draw parallels with other health problems in which an accurate diagnosis is needed before prescribing an intervention – baseline assessment is part of that diagnosis process. Another point to make is that by prematurely changing one thing, if it doesn’t work (maybe because it’s not the most important factor, or maybe because there has been insufficient time to learn it) this can reduce the person’s confidence in the overall process, making it more difficult for the person to be 100% committed to the subsequent steps.

Reducing time in bed not sleeping
It doesn’t seem to make sense that to help promote better sleep, initially at least, it can be important to reduce the amount of time actually spent in bed! ‘But if I’m not in bed I’m not going to sleep at all!’ can be one cry, while another is ‘but I’m far too tired to stay up, I need to go to bed as soon as I start feeling tired so I’ll fall asleep then.’ Oh darn.
The rationale behind reducing the time spent in bed while awake is based on a behavioural model of insomnia. When a person remains awake while in bed, he or she may be resting and enjoying that time, but most likely the person is feeling stressed, worrying that he or she isn’t sleeping, and getting more frustrated all the while! What then happens is the association between being in bed and being awake is strengthened – along with the unpleasant emotions and thoughts that go along with being awake when wanting to be asleep.
What can you say as a clinician? It’s important to use the information gleaned from the sleep diary collected during the week before starting intervention, and to use this so the person discovers his or her own reasons for extending the time in bed – and its failure to address the problem. Sometimes reviewing the ‘workability’ of the habit (ie ‘Is this working for you? Are you getting more sleep?’) can challenge the helpfulness, while at other times it offers an opportunity to illustrate the learned association between walking into the bedroom to go to sleep and putting the head on the pillow but remaining wide awake. By using the person’s own information and own discovery process, it becomes far easier for you as clinician to introduce a different approach – suggesting that while the person isn’t actually getting to sleep for a couple of hours, it might be useful to only get into bed when the chance of falling asleep is high. In other words, setting bedtime a lot later! (shame our patients aren’t our kids, huh?!)

It’s worthwhile reviewing the behavioural model of insomnia again when introducing the idea of delaying bedtime – especially flagging to the person that it’s highly likely that they’ll initially have a hard time getting off to sleep even with a delayed bed time.  Why?  Because of that conditioned response – bed = awake!  By ‘innoculating’ the person to the chance that they’ll have some delayed sleep onset initially, it can help them to persist with what might not look like a very helpful strategy at first!

At the same time as introducing the idea of a later bedtime, now is a good opportunity to discuss getting out of bed if awake during the night.  Again this is not likely to be greeted with particular enthusiasm, especially during winter!  The temptation is to stay in bed – but if the person isn’t sleeping, this only serves to perpetuate the association between being awake and being in bed.  By guiding the person through the logical consequences of being awake and remaining in bed even in the middle of the night, he or she is much more likely to understand and be more comfortable with the process of behaviour change.  This does mean getting out of bed in the middle of the night, and going to a quiet place with low stimulus for a while until ‘sleepy-tired’, then returning to bed when actually ready to fall asleep.

This new habit is most likely to provoke a thought like ‘If I lie on the couch, I might fall asleep there – at least I’m getting some of that sleep that I need’. It’s really important to catch that thought and check in on whether it’s going to be helpful long-term – and you know I’m going to suggest that it’s not!  The reason it’s not is the same reason I’ve discussed above: the association between being awake and being in bed needs to be weakened, while the association between being asleep and being in bed needs to be strengthened.  Sleeping anywhere other than the bed (and at the correct time of night) reduces the strength of the relationship between bed and sleep and works against behaviour change.

I’m going to stop here for today – there are quite a few more aspects that I’ll discuss tomorrow, if you’re up to it.

Oh… to sleep – CBT for insomnia in chronic pain
There are very few people who have chronic pain who have sweet dreams all night and wake feeling refreshed – having disturbed sleep and waking feeling grouchy seems to come with the territory for so many of the people I’ve seen with chronic pain! If it’s not difficulty staying asleep, it’s difficulty getting off to sleep, and if it’s not that, it’s feeling like the sleep that has been had simply isn’t good enough. So to find an effective approach to managing sleep problems without medication sounds a bit like a Holy Grail.  There is good reason to ensure restful sleep – studies show that poor sleep increases pain the following day, while a high pain day increases the risk of even poorer sleep that night.

And yes, there is a way to treat sleep problems in chronic pain without medication – but there is a downside, as always – it’s quite hard work!

Cognitive-behavioral therapy for insomnia (CBT-I) is a well-established approach for helping people return to a refreshing sleep pattern.  It involves several strategies including:

  • sleep restriction,
  • stimulus control,
  • sleep hygiene,
  • cognitive therapy devoted to catastrophic thoughts about the consequences of insomnia

Sleep restriction refers to restricting the amount of time spent in bed overall, and can mean reducing the amount of time attempting to sleep.  For example, if a person hasn’t been falling asleep until after midnight, and has fairly disrupted sleep with several wakenings during the night, maybe achieving 5 hours sleep in total, sleep restriction would mean not even attempting to go to bed until five hours before he or she wants to wake up.  Needless to say this can be pretty challenging for the person!

Stimulus control includes removing things like the clock from the room (too easy to keep looking at the clock and counting the hours awake), staying out of bed if not asleep, taking the radio and TV out of the room and using bed for sleep and sex and nothing else.

Sleep hygiene includes the above, but also introduces things like avoiding coffee or other stimulants before bed, keeping the room temperature warm-but-not-hot, exercising in the afternoon rather than late, avoiding eating in bed or during the night and so on.  Relaxation techniques and other soothing strategies are also included.

Finally, cognitive therapy for catastrophic thoughts about not sleeping is used to reduce that sinking feeling about lying awake ‘all night’ and thinking ‘I’ll never cope with the coming day’.  Some of the thought challenging that can be used here involves recognising that it’s actually possible to keep going on very little sleep; that while carrying out things like sleep restriction it’s no worse than having insomnia; and using positive statements like ‘it’s only for a while’ and ‘if I just take it easy over the day I’ll get through’.

Jungquist and colleagues conducted CBT-I for people with chronic pain in the study I’ve referred to today.  Now while this is a small group of people, this is a group of people with chronic pain – most of the previous studies on CBT-I have been with people who have primary insomnia, or insomnia that is not associated with another medical problem.  People with chronic pain often attribute their poor sleep to their pain, rather than any other factors, so it’s interesting that pain intensity didn’t change, although the interference of their pain on everyday life (as measured by the MPI, Multidimensional Pain Inventory) did improve.

This study protocol used an eight-week programme covering the strategies I’ve described above, and I’m immediately jealous because it’s common for me to see people for 12 weeks (once a week) to cover not only poor sleep, but also activity management, understanding chronic pain, developing relaxation responses, communication etc etc!  8 sessions are not a lot of sessions, and by comparison with the short-term effects of taking medication, these skills will last a lifetime.

While this study clearly demonstrates that CBT-I is an effective approach for people with chronic pain who also have the common symptom of poor sleep, I wonder whether this will influence the GP or pain physician tendency to prescribe sleep medication.  Taking a medication is a mixed blessing – some people with chronic pain prefer to take a pill because it’s easy, quick, acts fast, and is a known entity.  It’s also not a ‘psychological’ treatment.  Other people don’t like medications because of fears that it will lead to addiction, disliking side effects, the need to remain alert at times during the night because of children, or because medications can be ineffective.

I have seen that if a simple, quick and easily taken medication is available concurrent with a difficult, long-term, self-managed approach, it’s more probable that the person will take the pill in a high-risk or set-back situation.  Self management is not the easy way!

Self management through CBT-I doesn’t have to be carried out by clinical psychologists.  Suitably trained and experienced clinicians of many persuasions including, as in this study, nurses, but also occupational therapists, social workers, physiotherapists and others can deliver CBT-I to people with chronic pain.  It’s now more a case of GP’s and patients recognising that a non-drug approach is effective, and making sure funding agencies support delivery of this type of treatment.  At the very least it should be provided with the same amount of enthusiasm and support as medication for insomnia.

Jungquist CR, O’Brien C, Matteson-Rusby S, Smith MT, Pigeon WR, Xia Y, Lu N, & Perlis ML (2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep medicine, 11 (3), 302-9 PMID: 20133188

If you’re not asleep, get out of bed!
If you’ve read the sleep hygiene information I posted yesterday, you’ll read that it’s not a good idea to stay in bed if you’re not asleep.  Here’s another version. Beds are for sleep and sex, not for being awake – because our brains are very good at learning to put two and two together to come up with PING! Bed = Awake.  Much of the sleep hygiene approach involves reducing the association between stimulus and response, and by reducing any influence of stimulants, or factors that interrupt the sleep architecture.

For a great review of CBT approaches to sleep problems in people with chronic pain, Nicole Tang has written a nice review looking at various aspects of sleep and pain – and the CBT approaches that have been recommended and studied.   But – I’m not going into detail about this paper, that’s your job.  Today instead I want to look at one of the first studies into the use of sleep restriction as a therapy for insomnia, written by Spielman, Saskin and Thorpy in 1987.  I’m doing this because the paper they wrote discusses some of the underlying principles for using sleep restriction – and the paper clearly describes how to go about the intervention.

Sleep restriction is based on the idea that one of the factors that maintains insomnia is staying in bed while not sleeping.  Simply put, sleep restriction involves setting your bedtime by establishing the number of hours you actually sleep and going to bed that same number of hours before you intend to (or ordinarily) get up.  By introducing a little bit of sleep deprivation initially this approach increases the likelihood you’ll fall asleep quickly – consolidates the sleep actually achieved, producing daytime fatigue that may reduce the hyperarousal that people with sleep problems often have, and also minimise the time spent in bed wide awake.

Another aspect of this approach is to ensure the consistent bedtime, and more importantly, the consistent wake-up time, reduces the anticipatory anxiety many people experience when they’ve had trouble with sleep – that ‘Oh no, will I ever get to sleep tonight’ thought chain.

The details

In this original study by Spielman, Saskin and Thorpy, participants in the study recorded their sleep pattern for two weeks prior to the intervention.  The ‘average subjective sleep total sleep time’ was used to calculate the amount of time in bed used at the start of the programme.  For example, if the person thought they achieved a total of 5 hours sleep each night, at the beginning of the programme the ‘time in bed’ was set at 5 hours.  The wake-up time was set according to normal work schedules, so the person only went to bed 5 hours before they were due to wake up.  No person was required to have less than 4.5 hours time in bed.

Over the eight weeks of this programme, participants recorded their total sleep time, the time they went to bed, and their wake-up time in the morning.  From this data, ‘sleep efficiency’ was calculated – this is the ‘estimated total sleep time/time in bed x 100%’, combined with the sleep efficicency values for the previous 4 days, to arrive at a mean over 5 days.  This calculation was then used to guide the sleep schedule changes – with some very specific guidelines.

(1) When the mean sleep efficiency over the previous 5 days was 90% or more, then the person was able to add 15 minutes to their total time in bed – in other words, go to bed 15 minutes earlier

(2) When the mean sleep efficiency over the previous 5 days was less than 85%, the time in bed was reduced – but not until 10 days after the start of the treatment, or for 10 days after a change had been made to the sleep schedule.  Time in bed was reduced to the mean sleep time over the previous 5 days.

(3) If the mean sleep efficiency was between 85 -90%, then the time in bed wasn’t altered.

The only other ‘rules’ were not to lie down or nap at anytime other than bed-time.  There were no changes to caffiene intake, food, tobacco, exercise or even whether to stay in bed when they weren’t able to sleep.

The results

Using ANOVA, baseline and end of treatment analyses were carried out.  Time in bed, sleep latency (how long it takes before falling asleep once in bed), total time awake, total sleep time and sleep efficiency (as previously described) were all analysed.  The results looked good – mean total sleep time over the group of 32 participants went from 320 minutes to 343 minutes, (P<0.05), sleep efficiency went from 67% to 87%, and the time it took for people to fall asleep went from 48 minutes to 19 minutes.

What can we conclude from this?

Well, this study was quite small, the participants were not people with chronic pain, and the follow-up period was weeks rather than months.  The drop-out rate was also reasonably high, and there were comments about difficulty complying with the instructions.  All of which means it’s important not to draw too many conclusions from this study alone – thankfully, however, sleep restriction has been studied in much more depth since this original work.

I’ve written in detail about the procedures used in this study, because so often it’s difficult to find out exactly how to carry out a specific strategy like sleep restriction.

Practical problems that were found in this study haven’t really changed much – I’ve had people not carry on with sleep restriction because ‘it annoys my husband’, ‘I couldn’t function the next day when I tried to drop the kids off to school’, ‘I kept forgetting the time I was meant to get into bed’, ‘I kept falling asleep on the couch before my bedtime’ – and so on.

For people with whom I have used this approach successfully, what is surprising is how quickly their sleep pattern consolidated and they were able to maintain good sound sleep thereafter.  Even during relapses into insomnia, the people who used this approach were able to quickly return to their sleep restriction and get back into a normal sleep pattern over days rather than weeks.  It’s also a useful approach for people who don’t want to use medication for sleep, or who can’t use tricyclic antidepressants.

One interesting finding is that reduced pain doesn’t make an awful lot of difference to sleep quality – and vice versa, better sleep doesn’t appear to change pain all that much.  What is different is the feeling of being more refreshed and more positive, making it easier to manage the pain.  And that’s why I’ll still help with sleep problems as a priority.

More on sleep soon – stay tuned!

Tang NK (2009). Cognitive-behavioral therapy for sleep abnormalities of chronic pain patients. Current rheumatology reports, 11 (6), 451-60 PMID: 19922736
Spielman AJ, Saskin P, & Thorpy MJ (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10 (1), 45-56 PMID: 3563247

To sleep, perchance to dream…
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.

Friday funnies!

It’s nearly Labour Weekend in NZ, time for all good DIYers to get their projects up and running.  For inspiration, you might like these…


And if none of those tickle your fancy, think about one of these as a weekend project.
Yes, they’re cakes. Not for the faint-hearted or those with hand tremors.
Finally, if you want to know whether you really need a break – take this test. It’s from the Beebs, can’t be wrong! Have a good one.

Health and Science Trivia Day!

Todays a good day for kicking back and enjoying some curious, quirky bits of trivia from the health and science world. No, not the sort I had from last time (you know, that has been one of my most visited posts???!), more like this one about your spleen.
I love that word ‘spleen’ – it’s a most wonderful almost onomatopaeic word, and I have always wondered how on earth you vent one!

Anyway, that particular article from Science Daily suggests that it is really an organ where important information from the nervous system (particularly the brain) reaches the immune system. The spleen is where immune cells are manufactured, and a site where immune cells and nerves interact. The spleen defends the body against infection, particularly encapsulated bacteria that circulate through the blood.

There, now you can sleep tonight.

From the same site (Science Daily), earlier this year researchers are quoted as confirming yet again that smokers not only smell bad, have more wrinkles and get cancer – but they also experience more back pain. (Well they actually said ‘suffer’ but as I’ve said before, experiencing pain is mandatory, suffering is optional – and OK they didn’t say smokers smell bad, have more wrinkles and get cancer – that’s my bias coming right on through). The back pain part is, however, very true.

The Robert Koch institute released a study conducted in 2003 showing that ‘smokers or former smokers suffer chronic back pain much more often than do non-smokers. The number of years the subjects had been smoking or had smoked was decisive. Subjects who had consumed tobacco for more than 16 years had a two-fold greater probability of suffering chronic back pain than subjects who had smoked for less than 10 years.

The probability of back pain was further multiplied for subjects who had smoked for longer than 26 years. On the other hand, the frequency with which the subjects consumed tobacco and the quantities smoked did not play a role.’

Now, I’m sure you’ve pondered this in the wee small hours of the night (especially if you’re studying, writing or having to get up to kiddies), but Nicole from New Jersy (yes really!) ask at Scienceline whether a person that hasn’t slept for three days can become legally insane.

The short answer is no – and the myth that sleep deprivation leads to hallucination is broken. Apparently this finding was obtained around 50 years ago when researchers saw that people who had been sleep deprived started to ‘hallucinate’. But actually it was found they were really dreaming while awake! Dr. Mark Mahowald, director of the

Minnesota Regional Sleep Disorders Center says “Dreaming actually occurs during wakefulness.” Hmmm, I didn’t know that.

But I did know that when you have had insufficient sleep for a long time, you experience ‘microsleeps’ which are ‘very brief periods of loss of attention associated with events such as blank stare, head snapping, and prolonged eye closure which may occur when a person is fatigued but trying to stay awake to perform a monotonous task like driving a car or watching a computer screen.’ Sort of what happens when you try to stay awake in meetings when you are not playing meeting bingo.

Finally, here’s a beauty spot:
Taken at Kaikoura a couple of weeks ago. Beautiful. And yes, that’s snow on those mountains. It was cold. But I didn’t get the blisters I got last weekend tramping in to Lake Daniels. Photo’s from that episode are in Flickr – click on the images to the left of this post.
Have a great weekend!!

Deutsches Aerzteblatt International (2008, July 3). Smokers Suffer More Back Pain, Survey Shows. ScienceDaily. Retrieved September 5, 2008, from­ /releases/2008/07/080701092149.htm
North Shore-Long Island Jewish (LIJ) Health System (2008, July 22). How The Immune System And Brain Communicate To Control Disease. ScienceDaily. Retrieved September 5, 2008, from­ /releases/2008/07/080721173748.htm

Sleep – pain – sleep – pain – sleep
Today a client and I were discussing sleep. She said to me
‘Why is it that I can’t get off to sleep because I’m so sore, then I have a bad pain day, I’m really tired,
and I still can’t go off to sleep, so the next day I have a worse pain day.’

We’ve known anecdotally and in cross-sectional studies that people who have pain often have poor sleep, and when they have poor sleep, their pain gets worse… It seems to work in both directions!
And now, with a well-designed naturalistic study by Edwards and colleagues, we have some good data on the nature of this relationship.

The study was carried out in a national sample of nearly 1000 people who were not patients, but were recruited as part of another study of ‘midlife’. Most of the people were in their mid-40’s, roughly 50:50 male/female, mainly white (90%) and married (81%). For eight consecutive evenings, participants were telephoned, and asked about their sleep and pain ratings. Other information was also gathered, but what is of interest to us as clinicians, is the relationship between sleep and pain and sleep and pain over consecutive nights.

Now, as usual I’m not going anywhere near discussing the mathematics involved in structural equation modelling. One day I’ll blog about it, but not today. If you want to go into more detail yourself – go and read the article yourself. However, the findings were surprisingly clear: sleep predicted subsequent sleep, pain predicted subsequent pain, sleep predicted subsequent pain, pain predicted subsequent sleep.

The authors themselves state “significant effects of previous sleep on next-day pain, and of previous pain on subsequent sleep were found. Interestingly, the relationship was somewhat stronger for the prospective association of sleep with subsequent pain (Beta = .08, Zvalue = 7.9, p < .0001) compared to the prospective association of pain with later sleep (Beta = .04, Zvalue = 3.1, p = .002).”

What this means is that poor sleep predicted increased pain better than high pain predicting poor sleep, but there was a relationship between the two.

In terms of analysing the effect of yesterday’s pain on today’s pain – well, again the findings were quite interesting. The previous days’ pain was more predictive of today’s pain than age, BMI, comorbidities, an emotional disorder or using prescription medication.

Again, quoting the authors of this study, “The results of the present study suggest a significant curvilinear prospective association of sleep duration with subsequent daily pain report; individuals sleeping for less than 6 h, or for 9 h or more, reported more frequent pain complaints the following day. Evaluating the extremes of sleep duration, sleeping for three hours or less was associated with an 81% increase in pain frequency relative to sleeping 6–9 h, and sleeping for more than 11 h was associated with a 137% increase in pain frequency.”

Now that is pretty useful information. Remember that this is a normal, nonclinical population – these people don’t (yet) have persistent pain for which they are seeking treatment. It suggests that attending to poor sleep may be useful to

(1) screen for individuals who may be at risk of developing persistent problems associated with pain

(2) that poor sleep may be part of a group of symptoms that may need to be considered together when we develop new analgesics

(3) day-to-day fluctuations in sleep may be important to consider when evaluating patients in pain. If the person has had poor sleep for several days prior to an appointment, their pain report may be higher than ‘typical’ for them – and the sleep disturbance could be due to factors such as anxiety about the appointment, creating a vicious cycle.

(4) management of poor sleep may need to be the focus of non-pharmacologic pain management to help people cope better with their problem.

Remembering the usual proviso’s for non-experimental methodologies (and that there is maths and statistics involved!), and as the authors acknowledge, multidimensional measures of both sleep and pain would more accurately measure quality of sleep and pain rather than merely quantity, and most importantly, this study involved self report of sleep – which is notoriously unreliable – it is still clear that this study provides us with some food for thought.

And especially given that our clinical population so often complains of poor sleep – perhaps developing an increased awareness of non-pharmacological sleep management would be a good idea.

ABERNETHY, A. (2008). Pain and sleep: Establishing bi-directional association in a population-based sample☆. Pain, 137(1), 1-2. DOI: 10.1016/j.pain.2008.03.022

EDWARDS, R., ALMEIDA, D., KLICK, B., HAYTHORNTHWAITE, J., SMITH, M. (2008). Duration of sleep contributes to next-day pain report in the general population☆. Pain, 137(1), 202-207. DOI: 10.1016/j.pain.2008.01.025

Why CBT? How do patients feel about it?

There are many different therapies out there – why is CBT (or one of the newer variants) the Chosen One?
I gave a few reasons yesterday –
* that people are capable of change,
* can accept self responsibility for their actions,
* that what we think and believe about a situation can affect our emotions and responses, and
* that we can implement a whole range of strategies that can make a difference to life
Here are a few more…

  • help people become more likely to stick to ‘other’ interventions
  • provide opportunities for people to reflect on the choices they make, especially the choices about healthy behaviour
  • help people recognise their own power and role within their own health care team, and their responsibilities
  • help people develop a sense of control over their own health
  • reduce the effects of stressors
  • reduce the misleading effects of anxiety and concern (e.g. reduce the search for a ‘cure’ or ‘another diagnostic investigation’

In chronic pain management there is plenty of research-based evidence that programmes building on these principles help people recover to a more normal life, and especially, return to normal life roles. CBT-based programme are not, however, very specifically prescribed – researchers still don’t know how much or what constitutes ‘necessary’ and ‘sufficient’ elements in a programme.

One of the main problems with initiating CBT-oriented therapy is that people with a health problem, especially pain, really DON’T want the slightest hint that their pain could be ‘imaginary’, ‘psychological’, ‘malingering’, ‘in my head’, nor about them being ‘unable to cope’. Introducing the idea of CBT initially can be quite challenging if it’s carried out as if it’s separate from any other aspect of the person’s health care. This is another strong reason for it to be integrated and conducted by any and all members of the team.

Introducing CBT

A lot of CBT books suggest ‘socialising’ the person to CBT – I’m not entirely comfortable with this idea myself! It sounds a lot like the demand characteristics of a therapeutic setting are being used to ‘make’ the person ‘conform’ to how I as a therapist want sessions to be run. My preference is to use the menu approach, as I think I’ve mentioned before. menu I’ve attached one for you to download if you want.

Once the person’s identified what they see as their concerns, I can start talking about some of the ways other people have worked through or solved their problems. This can often mean the person comes up with their own solutions – and my job is to then, with their permission, help them put that solution into a framework that can help them understand how or why it might work.

An example? One of the people I’m seeing currently has difficulty sleeping. She’s fine getting off to sleep, but just can’t stay asleep. She has worked out that she finds it really difficult to get comfortable again once she’s woken up, and then her mind becomes very busy.

Her thought for a good way to manage this was to work out how she could get comfortable more quickly – and she knew from the menu I’d used that learning how to relax might be helpful. We’ve started developing her skills in relaxation – but I’ve added in the following cognitive model to help her understand why it might work.

  1. She’s quite a busy person and doesn’t relax readily. She goes off to sleep very quickly because she’s very fatigued, but waits to go to bed when she’s really exhausted. As a result, she doesn’t allow herself to experience that relaxed dosiness that most of us get.
  2. When she wakes in the middle of the night, she’s recovered from some of her fatigue, so because she doesn’t know how to fall asleep again, she starts to become anxious – especially when she thinks of the coming day, and how much she needs to have good sleep!
  3. As she starts to worry, her body starts to respond to the increased anxiety, and she becomes more aroused physiologically – this increases her general anxiety and she becomes more aware of (and hypervigilant to) her back pain. She also has less to distract her from her worries and her pain because it’s quiet and she is alone.

I also took the time to discuss the stress response – and she was able to identify a number of factors that are increasing her anxiety at present, and how this is experienced in her body. She arrived at the conclusion that prior to her back pain, she was able to ‘work off’ some of her ‘stress’ by keeping very busy and by carrying out fitness activities also. Without her usual outlets for ‘stress’ she reflected to me that she has been finding it harder to wind down.

At the same time as identifying the stress, pain, arousal, sleep problems – this woman has also identified that she’s not sure why she keeps so busy all the time. She’s pondering this and it may be something she discusses with the psychologist on our team. And next time we meet, she intends to see how the relaxation process we went through has worked – and she’s also been given some other information on sleep hygiene to review.

Without even attempting to ‘socialise’ her to CBT, a common structure for CBT sessions is developing – starting each session with an ‘agenda’ or menu, reviewing her past learning (‘homework’ -ugh! missions if you please – you do have a choice about whether you want to accept them or not!), identifying the elements that have worked well, those that haven’t, and reviewing new pieces of information as we go.

For my next post, I’ll describe a situation that hasn’t moved so smoothly so you can see that it doesn’t always work out exactly as I want! But in this case, I think I’ve been able to start where she is at, give her the responsibility to identify what is important to her, and the solutions she has identified (which demonstrates my belief that she has the resources to cope and increases her confidence in herself), help her fit the solutions she has come up with into a framework that makes sense and opens up an opportunity for more factors to be added in for future exploration.