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  • Writer's pictureMatthew Corbin D.C

Twilight Discomfort: The Link Between Poor Sleep and Chronic Pain.

I'm sure most of us at one time or another has had a bad night's sleep. Emotional problems, bills, study, relationships, menopause, nightmares, work, health, something you said or something you didn't do AND Pain. We can cope pretty well with short term sleep issues and stress, but when it becomes chronic it gets harder to deal with.

This blog is all about the link between sleep and pain, or pain and sleep. Which came first? With any new patients that come through my doors here in Cardiff, I always ask about sleep. Why? Because it's so important, it's when we heal, process our thoughts and creates the cells in our body to keep us functioning properly. (Don't worry tips to tackle this issue will follow).

So is there a link between sleep and pain?

In short yes, and the link is strong. A large percentage of chronic pain patients have poor sleep. Short term pain too, but because it's fleeting pain, the sleep is restored with short term pain.

Poor sleep and pain are closely interconnected, with each potentially influencing and exacerbating the other. Here's how they are linked:

1. Increased Pain Sensitivity: Lack of sleep can increase pain sensitivity, making individuals more susceptible to feeling pain. This is because sleep deprivation can affect the way the brain perceives and processes pain signals. Research has shown that inadequate sleep can lower the pain threshold, meaning people might experience pain more intensely than if they were well-rested. When we are well rested we are in what's called homeostasis. We are functioning at optimimum with little in the way of stressors. When we are deprived of sleep we are producing catchup hormones which doesn't feel so great. People who have fibromyalgia can struggle with sleep, have intermittent flare ups and resolution of pain.

2. Inflammatory Responses: Poor sleep can trigger an increase in inflammation in the body, which is a common pathway for the development of pain. Chronic inflammation can lead to or exacerbate painful conditions such as arthritis, back pain, and other musculoskeletal disorders. Inflammation greatly impacts everything from mood, to digestion to pain.

Image of inflammation through the body
A depiction of inflammation through the body

3. Impaired Healing: Sleep is crucial for the body's healing processes, including tissue repair and immune system functioning. When sleep is compromised, the body's ability to heal and recover from injury or illness is diminished, potentially leading to prolonged pain or the worsening of pain conditions.

4. Emotional and Psychological Effects: Sleep deprivation can affect mood, leading to increased feelings of stress or depression, which can in turn increase the perception of pain. The psychological state can greatly influence one's experience of pain, with stress and anxiety often exacerbating pain sensations. Have you ever been snappy after a bad night's sleep? Now you know why!

5. Disrupted Pain Inhibition: Sleep helps regulate the body's pain inhibition pathways, which help to dampen and modulate pain signals. Poor sleep can disrupt these pathways, leading to less effective pain control and higher pain levels.

6. Vicious Cycle: The relationship between poor sleep and pain is often cyclical; pain can lead to poor sleep quality or difficulty falling asleep, which in turn can exacerbate pain, creating a vicious cycle that can be hard to break.

Effective management often requires addressing both the pain and the sleep issues simultaneously. Strategies might include improving sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), pain management therapies, and possibly medication under the guidance of a healthcare provider. Breaking the cycle between poor sleep and pain is crucial for improving overall health and quality of life. Also we as chiropractors have some pretty good tricks up our sleeves

Let's get to know a little more about sleep. Let's call it sleep science:

A man in a state of deep sleep

Why do we sleep anyway?

Sleep, an essential function of the human body and remains one of nature's most intriguing mysteries. It is a fundamental process that affects every aspect of our health and well-being. Despite its ubiquitous nature, the exact reasons why we sleep are complex and multifaceted. Sleep has a few differentstages so i'll highlight the most critical phases for our health very shortly.

An image depicting the different stages of the sleep cycle
The Stages of Sleep from light to deep

Sleep serves numerous vital functions, including:

- Restoration and Healing: Sleep allows the body to repair itself. During sleep, the body can heal damaged cells, boost the immune system, and recover from the physical and mental exertions of the day. This is why exercise is one of the best solutions to a good sleep.

- Brain Function and Memory Consolidation: Sleep is crucial for cognitive functions, such as memory consolidation, learning, and problem-solving skills. During sleep, the brain organizes and stores memories, making it easier to recall information later. It is believed this is one reason why we dream. The brain putting different information into the filing cabinet.

- Emotional Well-being: Adequate sleep helps regulate mood and is associated with better emotional resilience and lower rates of depression and anxiety.

- Energy Conservation: Sleep reduces the body's metabolic rate and energy consumption, allowing it to conserve resources. It's believed that eating too much before sleep can make us feel more fatigued the next day because much of the energy has been spent on breaking down food.

- Growth and Development: In children and adolescents, sleep supports growth and development due to the release of growth hormone during certain sleep stages. Let kids sleep, they need it.

How much sleep do we need?

The amount of sleep you need per night varies significantly with age, and factors such as individual health and fitness levels can further influence these requirements. Here is a general guideline from the National Sleep Foundation and other health organizations regarding how much sleep is recommended for each age group:

- Newborns (0-3 months): 14-17 hours each day.

- Infants (4-11 months): 12-15 hours including naps.

- Toddlers (1-2 years): 11-14 hours including naps.

- Preschoolers (3-5 years): 10-13 hours including naps.

- School-age children (6-13 years): 9-11 hours.

- Teenagers (14-17 years): 8-10 hours.

- Young adults (18-25 years): 7-9 hours.

- Adults (26-64 years): 7-9 hours.

- Older adults (65+ years): 7-8 hours.

Fitness and overall health also play a role in determining how much sleep is necessary. Individuals who are highly active or engage in strenuous physical activities may require more sleep for optimal recovery and performance. Similarly, people with certain health conditions or illnesses might need more rest to support healing and well-being.

The Stages of Sleep

Sleep is not a uniform state; it consists of several stages that cycle throughout the night in roughly 90-minute intervals. These stages are divided into two main types: Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep.

NREM Sleep:

1. Stage 1 (N1): The transition phase from wakefulness to sleep, lasting several minutes. It's characterized by slow eye movement and reduced muscle activity.

2. Stage 2 (N2): Light sleep before entering deeper sleep. Heart rate slows, and body temperature drops. Brain waves show a new pattern, with occasional bursts of rapid waves called sleep spindles.

3. Stage 3 (N3): Deep sleep or slow-wave sleep. It's harder to awaken from this stage, and it's crucial for physical recovery, immune system strengthening, and energy restoration.

REM Sleep:

A depiction of deep REM sleep

- REM Sleep: Occurs approximately 90 minutes after falling asleep. It's marked by rapid eye movements, increased brain activity, and vivid dreams. REM sleep plays a critical role in memory consolidation, learning, and emotional processing.

The Most Important Stages of Sleep

While all stages of sleep are important, N3 (deep sleep) and REM sleep are particularly crucial for overall health.

- Deep Sleep (N3): This stage is essential for physical health, as it supports growth and repair of tissues, boosts immune function, and replenishes energy stores. Deep sleep helps with cognitive functions and emotional health by detaching from the senses and allowing the brain to rest.

- REM Sleep: Critical for brain functions, including memory consolidation, learning, and emotional regulation. REM sleep stimulates areas of the brain essential for learning and developing new skills.

Let's get back to the pain

A woman unable to sleep due to back pain

As I mentioned some of the people I see in clinic have poor sleep, most commonly associated with depression and other mood disorders. What came first, depression or poor sleep? If sleep regulates our mood and we don't get good sleep is that the cause? Well no, because depression is probably more complex than poor sleep. So they both need to be addressed. The problem is, first medication will be given for depression, which helps for some people, and they'll often be given sleep medication on top. I don't know many patients that tell me they work sadly. In fact the medication can lead to other side effects.

The connection between sleep and depression is bidirectional, meaning that just as depression can lead to sleep problems, poor sleep can exacerbate or even contribute to the development of depressive symptoms. Here are some reasons why individuals with depression might struggle with poor sleep:

1. Altered Brain Chemistry: Depression is associated with changes in brain chemistry, particularly in neurotransmitters like serotonin and dopamine, which are also involved in regulating sleep patterns. These changes can disrupt the natural sleep cycle, leading to difficulties falling asleep, staying asleep, or experiencing restorative sleep.

2. Ruminative Thoughts: Individuals with depression often report difficulty quieting their mind at night due to ruminative, negative thoughts. This state of mental hyperarousal can make it challenging to fall asleep or lead to frequent awakenings throughout the night.

3. Altered Sleep Architecture: Depression can alter the structure of sleep, affecting the duration and quality of different sleep stages. People with depression may experience less deep (slow-wave) sleep and reduced REM sleep latency, meaning they enter REM sleep more quickly than usual. These changes can impair the restorative aspects of sleep, leading to a feeling of non-restful sleep.

4. Circadian Rhythm Disruptions: Depression has been linked to disruptions in the circadian rhythm, the body's internal clock that regulates sleep-wake cycles. These disruptions can lead to insomnia (difficulty falling or staying asleep) or hypersomnia (excessive sleepiness), both of which are common in people with depression.

5. Increased Stress and Anxiety: Depression often coexists with anxiety disorders, which can exacerbate sleep difficulties. The physical sensations of anxiety, such as increased heart rate and muscle tension, can prevent relaxation necessary for sleep.

6. Lifestyle Factors: Individuals with depression may engage in behaviors that further disrupt sleep, such as irregular sleep schedules, increased screen time before bed, lack of physical activity, or substance use (e.g., alcohol, nicotine, caffeine), all of which can negatively affect sleep quality.

7. Medication Side Effects: Some medications used to treat depression can also impact sleep. For instance, certain antidepressants may contribute to insomnia or vivid dreams, while others might increase drowsiness.

I write about depression because that too is linked to chronic pain. Further increasing the complexities of sleep and pain.

Insomnia, what is it?

An abstract image depicting insomnia
An abstract illustration of Insomnia

Insomnia is a common sleep disorder characterized by difficulty falling asleep, staying asleep, or obtaining restorative sleep, despite having the opportunity to do so. This condition can lead to significant distress or impairment in social, occupational, or other important areas of functioning. Insomnia can be classified as either short-term (acute) or long-term (chronic), depending on its duration and frequency.

How Does Insomnia Start?

The onset of insomnia can be triggered by various factors, often involving a combination of psychological, physical, and environmental influences, such as:

- Stress: Concerns about work, health, finances, or family can keep the mind active at night, making it difficult to sleep.

- Irregular Sleep Schedule: Changes in sleep patterns or sleep environments, such as shift work or jet lag, can disrupt the body's circadian rhythm. I see many nurses who alternate between night shifts and day shifts, have issues with sleep.

- Poor Sleep Habits: Bad sleep habits, including an uncomfortable sleep environment or using screens before bedtime, can interfere with sleep.

- Mental Health Disorders: Anxiety, depression, and other mental health issues are strongly associated with sleep problems, including insomnia.

- Physical Illness or Pain: Chronic pain, respiratory problems, neurological disorders, and other medical conditions can lead to insomnia.

- Substance Use: Consumption of caffeine, alcohol, nicotine, and certain drugs can significantly affect sleep quality and lead to insomnia.

Symptoms of Insomnia:

Symptoms of insomnia include:

- Difficulty falling asleep at night

- Waking up during the night

- Waking up too early and not being able to fall back asleep

- Not feeling well-rested after a night's sleep

- Daytime tiredness or sleepiness

- Irritability, depression, or anxiety

- Difficulty paying attention, focusing on tasks, or remembering

- Increased errors or accidents

- Ongoing worries about sleep

What Does Insomnia Feel Like?

Experiencing insomnia can feel like a frustrating cycle of being tired but unable to sleep. During the night, individuals may lie awake for long periods, feeling anxious or stressed about not sleeping, which only compounds the difficulty of falling asleep. This can lead to a sense of dread or stress as bedtime approaches in anticipation of another sleepless night.

During the day, the lack of restorative sleep can lead to fatigue, mood disturbances (such as irritability or sadness), cognitive impairments (including difficulty concentrating or memory problems), and a decreased quality of life. The impact on daytime functioning can be significant, affecting personal relationships, job performance, and overall health. Sleep apnea is also another cause of poor sleep.

An image of a man that is struggling to sleep

I know, I know this all sounds like complete doom and gloom, I'm merely stating the facts and I'm sure the people reading this have ticked more boxes than a multiple choice exam. The more we know the more we have power over it. The biggest hurdle I see when it comes to lifestyle changes is the energy it takes to make changes. Many are fatigued so much that even the thought of putting an action plan into place is frightening. This leads to pessimistic thoughts, that lead to self justification to not do anything at all and becoming comfortable in a round about way with their pain and poor sleep. This is why people gave these issues for years, some since childhood, some young adults, and some recently in their later years.

If the list of things to do is too long, it becomes overwhelming. And it's easier to become overwhelmed when the sleep department is lacking.

So where do we start to improve sleep?

A man in deep sleep after drinking vodka

Start small, really small. The road to epic sleep does not happen overnight unless you've had a litre of vodka. And before you think that's a great idea, it isn't, alcohol is terrible for sleep. It actually destroys the most important parts of it.

So what are small steps?

They are the steps we aren't going to stress too much over. They are the steps less likely to overwhelm us, the steps that are achievable and the steps can can still pat ourselves on the back for.

A list of small steps:

A woman changing her bed sheets for better sleep

1. Establish a Regular Sleep Schedule: Go to bed and wake up at the same time every day, even on weekends. Consistency reinforces your body's sleep-wake cycle. This can be tricky with shift work but it's still doable.

2. Create a Restful Environment: Make your bedroom conducive to sleep—cool, dark, and quiet. Consider using earplugs, a fan, or a white noise machine to block out noise, and blackout curtains or an eye mask to eliminate light. Only use your bed for sleep, make your brain know that's what it's for.

3. Limit Exposure to Screens: The blue light emitted by phones, tablets, and computers can interfere with your ability to fall asleep. Try to avoid these screens for at least an hour before bedtime.

4. Exercise Regularly: Regular physical activity can help you fall asleep faster and enjoy deeper sleep. However, avoid vigorous exercise close to bedtime as it may have the opposite effect.

5. Mind Your Diet: Avoid going to bed either hungry or too full, as discomfort might keep you up. Also, limit caffeine and nicotine intake, especially in the hours leading up to bedtime, as they can disrupt sleep.

6. Establish a Pre-Sleep Routine: A relaxing routine before bed can help signal your body that it's time to wind down. This could include reading, taking a warm bath, or practicing relaxation exercises.

7. Limit Naps: If you choose to nap during the day, limit it to about 20-30 minutes and avoid napping late in the day, as this can interfere with nighttime sleep.

8. Manage Worries: Try to resolve your worries or concerns before bedtime. Jotting down what's on your mind can be a good way to transfer your thoughts out of your head and onto paper.

9. Seek Sunlight: Exposure to natural light during the day helps maintain a healthy sleep-wake cycle. Spend some time outside or in well-lit areas during daylight hours.

10. Consider Your Bedding: Make sure your mattress and pillows are comfortable and supportive. The quality of your bedding can significantly affect how well you sleep.

11. Limit Liquids Before Bed: Drinking too many fluids in the evening can lead to frequent bathroom trips throughout the night.

12. Try a weighted blanket: Weighted blanked have been shown to be beneficial for anxiety and calming the nervous system. It's worth a go, and it will keep you warm in winter.

An image of healing magnesium oil spray

13. Try magnesium oil spray: I know from my patients how well it works, they call magnesium the calming molecule. Not only does it improve sleep for many, it's great for restless leg syndrome. Be sure it's not going to interact with any medication you are taking.

14. Seek Professional Help if Needed: If sleep problems persist or have a significant impact on your quality of life, it may be time to consult a healthcare provider or a sleep specialist. Conditions like insomnia, sleep apnea, and restless legs syndrome often require professional help. But there is plenty of information out there to go us on the right track.

Back to the small steps:

A man stretching and yawning after a restful sleep

Start with just one step, choose one that resonates and one that is fairly easy to implement into your life. Do it consistently and it can pay off. It's amazing how small steps not only take us in the right direction, but also improves our mood through that sense of achievement. For someone who struggles with motivation, the small steps is a smaller peice to bite off.

The bigger steps:

A woman walking up a long staircase to a bed. Depicting the steps it takes to get a good sleep

When smaller steps are achieved, bigger steps can be achieved. This means taking multiple steps and even newer ones that have not been tried before. At this stage, it is less overwhelming to take bigger steps, many people will have already noticed a difference in their quality of sleep too.

The main bigger step, is asking for help. People often dread this. The thought of admitting there is a problem can be more painful than the actual issue. More so in men. So what are the bigger steps?

The current best therapies for Sleep:

Sleep therapies aim to address various sleep disorders, ranging from insomnia to sleep apnea, and involve different approaches depending on the specific condition and its severity. Remember chronic pain can be improved by better sleep, linking this entire blog (hopefully)

Here’s a list of common sleep therapies, their benefits, and their success rates:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

- What it is: A structured program that helps identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep.

- How it works: CBT-I involves techniques such as stimulus control (associating the bed with sleep), sleep restriction (limiting the time spent in bed), relaxation techniques, and sleep hygiene improvement.

- Success Rate: Considered highly effective, with studies showing that 70-80% of participants experience significant improvements in sleep quality and duration.

2. Sleep Hygiene Education

- What it is: Education about good sleep practices and habits that promote restful sleep.

- How it works: Involves advice on regulating sleep schedules, creating a conducive sleep environment, diet and exercise recommendations, and reducing stimulant intake.

- Success Rate: While beneficial for mild sleep issues, it’s often used in conjunction with other therapies for more significant sleep disorders.

3. Positive Airway Pressure (PAP) Therapy

- What it is: Commonly used for sleep apnea, PAP therapy involves wearing a mask that delivers air pressure through the nose and/or mouth to keep the airway open during sleep.

- How it works: The constant flow of air prevents airway closure, thereby reducing apneas (breathing pauses).

- Success Rate: Highly effective for obstructive sleep apnea, with compliance rates affecting success. Continuous use is associated with improved sleep quality, daytime alertness, and overall health.

4. Oral Appliance Therapy

- What it is: A treatment for sleep apnea and snoring, involving a custom-fit device worn in the mouth during sleep.

- How it works: The device adjusts the position of the lower jaw and tongue to keep the airway open.

- Success Rate: Effective for mild to moderate obstructive sleep apnea and snoring, with success rates varying based on the appliance type and patient compliance.

5. Medications

An image of sleep medications on a bedside table

- What it is: Pharmacological treatments prescribed for various sleep disorders, including insomnia and restless legs syndrome.

- How it works: Medications can include sleeping pills, melatonin supplements, antidepressants, and drugs targeting specific sleep disorders, affecting various neurotransmitters to promote sleep.

- Success Rate: Effectiveness varies widely based on the drug and the disorder being treated. Generally, medications are more effective when combined with behavioral therapy and used on a short-term basis due to potential side effects and dependence.

6. Bright Light Therapy

- What it is: A treatment for circadian rhythm disorders, such as delayed sleep phase syndrome. Also called SAD lamps or lights.

- How it works: Exposure to a bright light box at specific times can help reset the body’s sleep-wake cycle.

- Success Rate: It has shown high efficacy in treating circadian rhythm disorders and some types of depression, with success depending on the timing and duration of exposure.

7. Relaxation Techniques

- What it is: Methods like progressive muscle relaxation, deep breathing exercises, and meditation aimed at reducing bedtime anxiety and promoting relaxation.

- How it works: These techniques help to lower the heart rate, reduce muscle tension, and shift focus away from stressors, making it easier to fall asleep.

- Success Rate: While individual results can vary, these techniques are generally effective in reducing the time it takes to fall asleep and improving sleep quality, especially when combined with other therapies.

8. Surgery (for Sleep Apnea)

- What it is: Surgical procedures to remove or reduce tissue in the airway, such as uvulopalatopharyngoplasty (UPPP) or maxillomandibular advancement.

- How it works: Surgery aims to enlarge the airway and reduce or eliminate the occurrences of apnea during sleep.

- Success Rate: Success rates vary depending on the specific procedure and the patient’s anatomy. Surgery is typically considered after other treatments have failed and is most effective when tailored to the individual's specific condition.

These therapies.

9. Hypnotherapy for sleep.

-How It Works

The process of hypnotherapy for sleep usually follows these steps:

1. Induction: The therapist uses techniques to help the individual relax deeply and enter a hypnotic state.

2. Deepening: Through further relaxation techniques, the therapist deepens this state to make the individual more receptive to suggestions.

3. Suggestion: In this state, the therapist introduces positive suggestions tailored to the individual's specific sleep issues. These might include visualizing calming scenes, changing attitudes towards sleep, or reinforcing the importance of sleep hygiene practices.

4. Awakening: The therapist gradually brings the individual out of the hypnotic state.

-Success Rates

The success of hypnotherapy for sleep can vary widely among individuals, depending on factors such as the specific sleep issues being addressed, the individual's responsiveness to hypnosis, and the skill of the therapist. While scientific research on the effectiveness of hypnotherapy for sleep disorders is still growing, some studies have shown positive outcomes, particularly for insomnia and nightmares.

- Insomnia: Hypnotherapy has been found to be beneficial for some people with insomnia, helping them to fall asleep faster and improve sleep quality.

- Other Sleep Disorders: It may also help with conditions like sleepwalking or night terrors by targeting the subconscious mind's control over sleep patterns.

Despite promising results, hypnotherapy might not work for everyone, and its effectiveness can be influenced by the individual's belief in and commitment to the process. It's often most successful when used as part of a comprehensive treatment plan that includes other therapies, such as cognitive-behavioral therapy (CBT) and sleep hygiene education.

As with any therapeutic approach, consulting with a healthcare provider to discuss the suitability and potential benefits of hypnotherapy for your specific situation is essential.

An image of a man having hypnotherapy for sleep

Can Chiropractic treatment help?

Chiropractic treatment can be very relaxing. I use many tools such as acupuncture, muscle relaxation techniques, manual stretching, facial techniques, cranial manipulation and words. Words are important because of interpretation. Through the power of words we can talk about someone's pain in a non threatening way. Especially when they have just come from a surgeon who said that their spine is crumbling. Spines do not crumble! By reducing pain the patient can get better sleep, which in turn reduces pain further. We also are good at motivating people to take small steps, which by now, you know they lead to bigger ones.

Hopefully after reading this you know most things about sleep, and why it's such an important part of our lives. Hopefully you can see the link between pain and inadequate sleep and what we can do about it. It's never too late to make small steps into bigger ones, for both pain and sleep.

Bonus Video:

You may have heard of him, a neuroscientist with a popular health podcast. Andrew Huberman. This is a great watch and I've picked up some great tips.



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