Chronic Pain and Sleep: How to Break the Vicious Cycle
The connection between chronic pain and sleep disturbances has been well established for some time now. However, our understanding of the relationship between the two has changed significantly.
Chronic Pain and Sleep Disturbances, a Reciprocal Connection
We use to think that the connection between chronic pain and sleep was unidirectional. In other words, a person’s sleep was being disturbed because of the discomfort caused by chronic pain. So the standard treatment was to treat the pain in order to cure the sleep disturbance.
And while treating chronic pain will certainly help patients to sleep better, it’s not the whole story. It turns out that the two conditions are much more interconnected than originally thought.
Sleep and Pain: The Effects of Pain On Sleep
It may seem like a simple connection, after all everyone knows that it’s hard to sleep when you’re in pain. That’s pretty obvious. What’s not so obvious is that sleep is affected not just by pain, but the type of pain experienced.
Sharp Acute Pain – Sharp acute pain is usually the result of an injury or accident. It is generally of a shorter duration. Examples include sprained ankles, broken bones and deep bruising. This pain is generally intense in the beginning and gradually gets better.
How it Affects Sleep – It is nearly impossible to sleep with the onset of sharp acute pain as it is often caused by trauma or blunt force injury. This releases stress hormones designed to promote a heightened sense of awareness.
Dull Acute Pain – Dull acute pain generally does not have a quick onset, and the pain can start off relatively minor, increasing in intensity over time. Dull acute pain is oftentimes caused by prior (old) injuries that have become irritated as well as nerve pain caused by trauma or diseases such as diabetes and fibromyalgia.
How it Affects Sleep – With the initial onset of dull acute pain, there may be little to no sleep disturbance at all. However, as the intensity of the pain increases, dull acute pain can interrupt the REM (deepest) phase of sleep. And if the pain continues to worsen it can cause people to wake up frequently and even cause insomnia.
Sharp Pain – Sharp pain can either be acute, lasting no more than 6 months, or chronic if it lasts longer than 6 months. Sharp pain is described with words like shooting, stabbing, throbbing, stinging or burning, with a relatively high level of intensity. Most of the time the intensiveness of sharp pain will vary and is often reported to come and go in “waves”.
How it Affects Sleep – Sharp pain is the most detrimental type for sleep. Often suffers are unable to fall asleep at all. If they do manage to fall asleep they can wake up often due to a surge in the intensity of the pain.
Sleep and Pain: The Effects of Sleep On Pain
When talking about how sleep affects pain, it’s important to note that pain consists of two parts. The first is the objective stimulus and the second is the subjective feeling.
Let’s use getting stuck with a needle as an example. When you get pricked with a needle, the first thing that happens is that the nerves start firing, sending signals to the brain that you are being stuck. This is the objective stimulus.
After the initial pain signal registers the type of pain (a needle stick) and the location of the pain (the arm). The pain signal then gets sent to the part of the brain that processes emotions. Here is where we experience the subjective part of pain. Qualities like the severity of the pain, whether it’s acute or chronic and how tolerable it is.
It’s this subjective part of pain that sleep disturbances affect. Most of us are familiar with waking up tired in the mornings and feeling cranky. This is certainly true of toddlers who don’t get enough sleep! The reason for this lies in how lack of sleep affects our perception of outside stimuli.
When normal sleep is interrupted and we wake up tired, our perception or sensitivity to outside stimulus is magnified. Normal things like noises, light and even activity can seem so intense as to be intolerable.
This is the same process that happens with pain. Without proper sleep, we become more sensitive to pain which makes the perception of the pain more intense.
Unfortunately, the traditional ways we treated pain often made the problem significantly worse.
Pain Management Techniques and Sleep Disturbances
For years, the standard treatment for pain was to prescribe an analgesic (often an opioid) to relieve the perception of pain. This was thought to allow the patient enough relief for them to return to a relatively normal state.
However, the unintentional consequences of this standard treatment often lead to a significant increase in chronic pain. But just exactly how does this happen? There are 4 main ways:
1 – Aggravation and re-injury – Pain is the body’s natural warning system designed to tell our brain when something is wrong. So by taking medicine that dulls the perception of that pain, you risk a continued aggravation of the injury. This can turn a temporary problem into a permanent one.
2 – Pain medicine and drowsiness – A side effect of most analgesics (especially opioids) is drowsiness. This causes lethargy and can lead to daytime sleeping. If you are sleeping during the day, there’s a good chance you won’t be sleeping at night. This is especially true because at night, there are less distractions from the pain.
3 – Opioid-induced sleep-disorder – All opioids are central nervous system depressants. As such, diminished respiration is a result. When we are awake this is usually not a problem. However, during sleep our respiration in already low, so when we add an opioid, breathing is further reduced. This can lead to hypoxia, starving the brain and other organs of oxygen. Over time, this leads to organ failure. It is also believed that opioid use can cause sleep apnea, a potentially fatal sleep disorder.
Combination Therapy, A Better Alternative
As it turn out, the best treatment option for most chronic pain patients is a combination of medicines (anti-inflammatories and analgesics), sleep hygiene and physical therapy.
Anti-inflammatory medicines can be effective in relieving pain caused by inflammation. Specifically arthritis, gout, and soft tissue injuries.
Analgesics can be very useful in the relief of short term acute pain, such as after a traumatic injury or surgery. However, longer term use of analgesic agents (particularly opioids) can worsen pain.
Sleep hygiene and the treatment of sleep disorders can reduce pain symptoms dramatically. By reducing sensitivity from the stimuli causing the pain it becomes much more tolerable.
Physical therapy is another excellent treatment for chronic pain. Physical therapy uses physical treatments such as heat, massage and exercise to treat injuries.
We have done ourselves a great disservice over the years by ignoring the reciprocal relationship between pain and sleep. We can greatly improve the results seen by medicine and physical therapy by paying closer attention to the sleep patterns and hygiene of patients with chronic pain.
For more information and treatment options for pain and sleep, visit our blog here.
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