Do you live with chronic pain? Do you have trouble sleeping? I do, and I know I’m not alone. The numbers vary by source, from about 40% to 70%, but however you slice it, insomnia is common among people living with pain.
I was planning to write a piece on the pain/insomnia problem many moons ago, but put it off and put it off because I hadn’t figured out a solution yet. Well, sorry to say, I still haven’t, but perhaps this is a good time to discuss it anyway. Collectively we may be able to come up with ideas that can help all of us who are wrestling with this problem.
In a study about people dealing with chronic neck pain and chronic back pain, authors note:
One of these aspects is sleep, which may become seriously disturbed in these patients. Patients with low back pain seem to have a high prevalence of sleep disorders and are twice as likely to be hospitalized compared with low back pain patients without sleep disorders. Sleep disturbance impairs cognitive and physical functioning as well as quality of life, the pain threshold, and occupational performance, as well as incurring higher health care usage and costs.
Moreover,
Current research suggests that while disturbed sleep is a consequence of chronic pain, it might also contribute to disturbed pain modulation, pain perception, and hyperalgesia and may be a risk factor for the exacerbation of chronic pain.
(Prevalence of sleep deprivation in patients with chronic neck and back pain: a retrospective evaluation of 1016 patients)
Another article: Impaired sleep linked to lower pain tolerance
In other words, pain and insomnia exacerbate each other. For those of us with disabilities that cause pain, we need to figure out how to improve our sleep in order to reduce our pain.
First let’s look at the science of sleep, and then generate a list of tools to improve sleep.
Sleep
Optimally, a night’s sleep is about 7-8 hours in adults, cycling through several episodes of deep then lighter REM stages.
A poor night’s sleep has short term effects on your next day’s alertness and energy, your mood, concentration, judgement, ability to deal with stress, and memory ability. Sleep is restorative, especially the deeper levels of the cycle. After a bad night, not only do we feel like crap, but we’re unable to function effectively. That affects productivity and can be downright dangerous (eg. driving). A recent article explains how your neural network behaves differently, in a small study using electrodes measuring nerve/synapse activity in the temporal lobe newsroom.ucla.edu/...: it found regions of sleep-deprived brains were “dozing” even while the people were awake. It took their brains longer to register and process the world, and make conscious decisions.
When we wake frequently, we don’t descend as deeply into sleep, and lose its restorative effects. People in pain toss and turn seeking more comfortable positions. That can awaken us, or push us from deeper to lighter sleep without us even knowing it. We wake up not feeling rested.
This is even worse for the oldsters among us: besides the various degenerative medical issues associated with aging, and the hormonal effects of menopause, and the greater number of medications we take, there’s also a qualitative change in the nature of sleep. With age, our sleep cycles bypass the deepest phase, so even if we get a lot of hours, we don’t feel refreshed or healed.
Chronic lack of sleep also increases our risk of major long-term medical problems such as cardiovascular disease, hypertension, diabetes, and compromises our immune functions.
Strategies for improving sleep
I think of this as a toolchest full of many options which I use either regularly, or in combination, or intermittently or in emergency, as the situation warrants. I’ll run through the possibilities currently recommended in the sleep-improvement world.
It’s a given that each one of us, with our different disabilities and life situations, experiences pain differently. We also each have particular physical, logistical, and financial limitations that affect what tools we can use. Our response to the same strategies and medications also varies from one individual to the next, ie. what works for me might be ineffective for you, and vice versa. I’ll add specific notes about a few as to their usefulness to my own particular situation in italics (to keep that distinct from general recommendations). I hope you’ll chime in with what works for you. Specific ideas are welcome!
1. Basic “sleep hygiene”, i.e. daily routines.
- Establishing a regular relaxing bedtime routine, such as going to bed and getting up at the same time every day which establishes a regular circadian rhythm (since I’m retired I mostly able to), taking warm bath or shower (I soak in a hot tub right before bed which helps relax cramped muscles), reading a relaxing book. Try to avoid stressful thoughts, conversations or activities before attempting to sleep. (for me: since the election a year ago, I don’t read political news after suppertime)
- Conducive sleep environment: comfortable mattress and pillows (I use latex topper on memory foam). Cool temperature, in the 60s. A dark room. Avoid bright light from lamps, cell phone, computer, TV screen and wind down from electronics well before you plan to sleep (this is a hard one for me; I like to check local news and weather last minute). Not only is your brain stimulated by electronic content, possibly generating stress and cortisol, but the light itself disrupts your circadian rhythm. If you live or travel where there’s unavoidable light/noise, consider using eye shades, ear plugs, "white noise" machines such as humidifier or fan.
- Use your bed/bedroom only for sleep (and sex), as a way to link the setting to the portion of your life dedicated to sleep. (I can’t do this since my disability requires me to be lying down most of the day)
- Warm cup of herbal tea or milk before bed
- Short naps (no more than 30 min) can help to improve mood, alertness and performance, but have them before supper to avoid interfering with the upcoming night’s sleep. After lunch is optimal.
- Avoid stimulants such as caffeine and nicotine close to bedtime; some sources say stop before supper or even earlier. If you drink alcohol do so in moderation; it may help you fall asleep but it disrupts sleep in the second half of the night as your body processes the alcohol.
- Don’t go to bed hungry, but avoid eating a heavy meal too close to bedtime, which can be physically uncomfortable or cause acid reflux.
2. Exercise is great in many ways, including for sleep.
The CDC has a nice list of health benefits from regular exercise:
It can help:
If that wasn’t enough, exercise helps our sleep too (here’s one study). Going outside to walk, cycle, jog or workout has the additional benefit of exposing you to daylight, which helps establish your circadian rhythm. Most sources suggest avoiding strenuous exercise too close to bedtime, to allow your system to wind down, but find what works for you.
I know exercise is problematic for folks with disabilities. This is a good time in this piece for me to describe how my particular disability causes chronic pain, and how exercise fits into how I try to manage it.
Sidebar: my particular disability
I have severe degenerative scoliosis — curvature of the spine — which I only discovered at age 46 after hurting myself digging a hole in my backyard to repair a broken water line. Getting xrays after my pain didn’t go away, I saw the problem in black and white, a photo of one film posted below. My worst curvature is in my lumbar vertebrae, measured as 50° in 2005, the last time I got xrayed. I have compensatory curvature in my thoracic section also but my pain is mostly sourced in my lower back, left side, and radiates from there. If my curvature had been discovered when I was a teenager, a corrective brace or surgery might have arrested it, but that’s not possible as an older adult. I do wear a custom-made hard plastic brace, armpit to hip, at times I have to be up for hours, like at a social function or traveling, but it’s only for support. I spend most of my day lying down, and do lots of work and read on my ipad.
The good news is I can be up for a few hours at a time to visit with my children/grandchildren and go outside into nature, high priorities for me.
The bad news is this is a degenerative condition, with curvature increasing every year. I haven’t gotten xrays for 12 years because frankly I don’t really want to know how bad its gotten. I figure if I can manage my pain so it’s not excruciating, that’s good enough. At some point I may lose function below the waist, at which time I’ll make the next decision, possibly fusion surgery, although all the orthopedics I’ve seen say that’s 50-50, i.e., as likely to make pain worse as better. I’d be betting on the chance of avoiding or coming back from paralysis/incontinence.
Essentially my pain problem these days is from rampant spinal arthritis and consequent nerve impingement. The pain causes my muscles to cramp up which exacerbates the pain.
I have an array of strategies to manage it. I’m never pain-free but I can keep it manageable enough so I can function with a decent quality of life. In addition to the aforementioned strategies I also avoid much physical activity, more and more. Gardening is one of the joys of my life and I’ve had to scale that way back over the years. I’m lucky to be married to a very helpful and understanding husband who does all the heavy lifting in our household, among other things. I also do daily physical therapy exercises for strength, stretching and flexibility, a set devised and taught to me by a gifted PT tailored to my particular problem.
And exercise:
One activity I’ve found very effective in loosening my back muscles and energizing my body and spirit, is gentle bicycling in my neighborhood. I don’t go far or fast, but it takes me out to the nearby beaches and bays where I can see the natural world, the seasons turning, wildlife doing what they do....nature’s sublime beauty. I carry a light camera, take photos and compose nature reports. I fell last December hitting my shin hard enough for a bone bruise which prevented me from exercising, even walking for two months. When I started to recover from that I narfed my opposite knee somehow, and then into spring and summer two occasions of overdoing at gardening, hurting my back. As a consequence I couldn’t exercise, and one of the effects was worsening pain. It was such a gift when I was able to go out again, carefully, in late August.
Indoor exercise is effective too. I acquired a bicycle-machine when I couldn’t manage the bike yet, and we’ve both found it very handy now when the weather is too stormy for being outside.
All of this is to convey how valuable appropriate exercise can be if you suffer chronic pain. And if you hurt less, you sleep better….and then you hurt less.
4. Sleep aids: Behavioral
- distraction: audiobook or music (I listen to books that take me far away from my current world: historical fiction or science fiction)
- compartmentalize worries: make a list, or direct those thoughts away deliberately
- sex (shared or solo) (endorphins & oxytocin, remarkably powerful)
- meditation/hypnosis: guided audio: cd’s, mp3, iPod, youtube (I’m still looking for one that works for me)
- meditation/self-hypnosis self-generated: Several approaches, like body scan progressive relaxation, visualizing a happy place in great detail, focusing on a stimulus (listening to each rain drop fall on the roof), simple but absorbing mental tasks (eg. name a vegetable/fruit starting with each letter, A is for artichoke, B is for beet, visualizing each) (eg. 3-2-1 technique: Listen for and note three sounds, Note three neutral or comfortable body sensations, Allow three images to appear in your mind’s eye, and note them, Note two sounds, two sensations, and two images., Note one sound, one sensation, and one image., Note three sounds, three sensations, and three images. etc)
Visualize a happy beautiful peaceful place in your mind....
...close up
....or off in the distance
5. Sleep aids: Medications
- Over-the-Counter (OTC) for pain relief: (aspirin, ibuprofen, naproxen, acetaminophen & combos) (I vary among these depending on how I’m feeling on a given night, and try not to overload my liver or kidney (singular, long story))
- OTC for sleep: antihistamines, eg Unisom, NyQuil. (I use these occasionally but they leave me groggy the next day, and don’t work night after night)
- OTC herbal soporifics, like melatonin, valerian, turmeric/pepper (these haven’t been effective for me)
- Prescription (Rx) pain meds: opioids (eg. codeine, hydrocodone, oxycodone, tramadol) (I take tramadol round the clock, which has become more complicated to get now it’s schedule 4; thankfully my long-time doctor is understanding, and my xrays/MRIs are objective evidence for the cause of my pain) or muscle relaxants (I’ll take this when my back is seriously cramped up)
- Rx sleep meds: hypnotics, like zolpiderm or eszopiclone (in a sleep emergency I will take an Ambien although my doctor/insurance only allows a small number, so I do that only after days of no sleep when I have to be functional the next day) and benzodiazepines, like diazepam, clonazepam, or lorazepam (I have a few Xanax left over from my women’s care Nurse Practioner, but she’s retired now and that’s a finite and dwindling supply )
- cannabis, especially high-cbd content. High-cbd cannabis relaxes you without getting you high. It can help for unwinding and getting your mind off worries or your to-do list. (I am fortunate to live in a state where cannabis is legal, both medical and recreational. I know someone who grows, and I make a glycerine extraction also use an alcohol tincture. I make canna/coconut-oil cookies for my husband. I can’t smoke or vape, hurts my throat.)
My experience with sleep medications, and what studies say also, is that none are effective night after night, and in fact doing that can cause insomnia rebound. Another drawback is that, besides the OTC pain meds, most of these substances have lingering side effects that can cut into the next day’s functioning.
In summary, I have some strategies I have incorporated into my daily life, and others I use occasionally/intermittently. Even so, I often have trouble getting to sleep or I wake up at 2-3-4 am unable to get back to sleep. It’s a major ongoing problem that affects quality of life.
Now over to you —
Do you wrestle with insomnia?
How does your particular disability complicate your quest for regular sleep?
What strategies do you use — what’s been effective?
Any other insights or questions for the group we might crowdsource for solutions?
Please tell us about your experience in the comments.
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