Footstep 7

Sleep

Sleep is the third most important health impact for those with pain, so it makes sense to focus efforts on guiding people to sleep well.

This is not about promising a perfect night’s sleep every night. Your role is to share what we know about ‘normal’ sleep, thereby dispelling myths.

For instance, most adults need 7-8 hours sleep and older adults may need as little as 6 hours. It is normal for adults to wake between sleep cycles: this can be very 75-90 minutes, and mostly, we just quickly go back to sleep.

Cruically, you can also share techniques and resources that will help the patient to improve their sleep over a period of weeks.

Action to take

Get to know all about sleep

Here's a quick overview of current thinking around sleep and people with chronic pain:

Pain itself

  • Use mindfulness, progressive muscle relaxation or other distraction techniques
  • Review analgesia (if helpful)
  • Avoid long term sleeping tablets – if the patient uses these regularly, review and plan a slow and steady reduction

Bedroom comfort

  • Bedroom is for sleeping only and best kept dark, quiet and cool
  • Do not use any devices that emit blue light e.g. smart phones, tablets. They effect secretion of melatonin from the pineal gland and make it harder to get off to sleep

Mood changes

  • Untreated depression or anxiety may contribute

Lack of routine and daytime inactivity

  • Build fitness and activity
  • Try to set regular times each day for activity and rest
  • Set a consistent bed time and rising time (most important)
  • Have a consistent bedtime routine
  • Stick with this plan for several weeks to allow the body to adapt – even if there are setbacks

Unhelpful thinking about poor sleep

  • CBT-I may be helpful here (see separate article). Lots of worried thinking disrupts sleep
  • Use relaxation skills e.g. breathing exercises
  • Headspace may be a useful Mindfulness resource
  • Accept and reframe using phrases like the one at the beginning of this section

Side effects of medication

  • Medication may contribute to day time drowsiness and inactivity and interact with opioids/gabapentinoids so best avoided or only very short term
  • Avoid excessive day time napping – this will affect the quality of night sleep

Food and drink choices

  • Reduce or cut out caffeine
  • If having caffeine, avoid after lunchtime
  • Avoid drinking large quantities late in the evening if you wake needing to urinate
  • Alcohol and cigarettes reduce sleep quality for many of us

Remember medical issues: so obstructive sleep apnoea (OSA) or restless leg syndrome (RLS) may be contributing.

Explore the value of mindfulness resources such as apps

This aims to cultivate patience and trust that sleep will come. It does not induce sleep like medicines. Mindfulness works best if practised regularly. It can:

1) help breaking down the vicious cycle of insomnia by guiding attention away from unhelpful thinking and worrying about not sleeping.

2) reduce stress and anxiety, which increase our perception of pain; so it calms and regulates emotions and so deceasing our perception of pain or frustration of not sleeping.

3) help greater awareness of thoughts, feelings and body sensations so the person can respond better to the body’s need for rest, balalnce of exercise/activity and healthy eating to maintain a healthy lifestyle.

Resources for your patient


How to sleep well with pain - leaflet

A useful step-by-step guide for patients, from Live Well with Pain

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Extra resources for you

An article about assessing and managing sleep disturbance in patients with chronic pain:

An article about cognitive and behavioural therapies in the treatment of insomnia:

Explore the evidence supporting CBT-I and local patient access:

Sleep

Summary of key points

  • Sleep disturbance is common in chronic pain and an important changeable issue. A focus on both pain and sleep management is likely to yield a better outcome
  • It is important to discuss what normal sleep is for the patient
  • Sleep hygiene advice, relaxation strategies and CBT have the potential to improve both pain and sleep
  • It is important to assess and address co-morbid conditions such as depression/OSA/medication side effects
  • It may also be necessary to explore more on insomnia

Quick links