Most of the people who come to our clinic have a problem with pain and for many people, the pain has been around for a considerable time. When dealing with cases of persistent and longstanding pain, our job is to work out what factors are causing and perpetuating the problem. As Physiotherapists, we are trained to check thoroughly for all of the physical things that could be causing the problem. However, we also need to check on a number of other issues that can play a part in perpetuating pain. One factor that frequently gets overlooked is sleep, or rather lack of it.

Sleep disorders are very common. It has been estimated that at least one in every five adults suffers from chronic sleep problems (1). Good health is dependent on regular exercise, good nutrition and refreshing sleep. All these elements influence each other through complex interactions and a breakdown in one area, will impact on others and can result in ill health (2)(3). Persistent poor sleep patterns have been linked to a number of different conditions including migraine, cardiovascular disorders and some metabolic conditions, such as diabetes (3)(4)(5)(6)(7). Persistent sleep deprivation can also increase pain (8)(19). It is thought that people who have poor sleep patterns over long periods of time, develop what is known as central sensitization. This basically means turning up the “volume” on all pain. (10)

The most common type of persistent pain is low back pain. In this group of people, sleep disturbance is very common. One study revealed that 53% of chronic low back pain patients had insomnia, compared with only 3% in pain-free controls (9). Dealing with the physical issues that are contributing to the back pain usually improves disturbed sleep patterns. However it is also helpful to take stock of some sleep related activities and to address those that could be causing problems.

Getting back into a good pattern of sleeping requires some careful planning. The term “sleep hygiene” is often used to describe the steps that should be taken to make sure that sufficient good quality sleep is obtained. Here are a list of some Do’s & Dont’s that should be followed in order to maintain or to re-establish a healthy pattern of sleeping

Do:

• Go to bed at the same time each day
• Get up from bed at the same time each day
• Get regular exercise each day, preferably in the morning (There is good evidence regular exercise improves restful sleep)
• Get regular exposure to outdoor or bright lights, especially in the late afternoon
• Keep the temperature in your bedroom comfortable
• Keep the bedroom dark enough to facilitate sleep
• Keep the bedroom quiet – try thicker curtains, sleeping at the back of your house or even ear plugs to avoid being woken by noise
• Use your bed only for sleep and sex
• Use a relaxation exercise just before going to sleep or a relaxation tape
• Try muscle relaxation to help destress and unwind, e.g. a warm bath or a massage
• Keep your feet and hands warm. Wear warm socks and/or mittens or gloves to bed

Don’t:

• Exercise just before going to bed
• Engage in stimulating activity just before bed, such as playing computer games, watching an exciting program on television or movie, or having an important discussion with a loved one
• Have caffeine in the evening (coffee, teas, chocolate, etc.)
• Have alcohol in the evening or use alcohol to sleep (it may make you drowsy but it doesn’t improve sleep and you will wake to go to the toilet)
• Smoke before going to bed – nicotine is a stimulant and will keep you awake
• Read or watch television in bed
• Go to bed too hungry or too full
• Take another person’s sleeping pills
• Never take daytime naps or doze off in front of the TV in the evening – keep yourself awake with something stimulating or your risk resetting your body clock
• Command yourself to go to sleep. This only makes your mind and body more alert If you lie in bed awake for more than 20-30 minutes, get up, go to a different room (or different part of the bedroom), participate in a quiet activity (e.g. non-excitable reading or television), then return to bed when you feel sleepy. Do this as many times during the night as needed

References

1) Ford, E. S., Wheaton, A. G., Cunningham, T. J., Giles, W. H., Chapman, D. P.,
& Croft, J. B. (2014). Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among US adults: Findings from the national ambulatory medical care survey 1999-2010. Sleep, 37 (8), 1283–1293.

2) Lindström, J., & Uusitupa, M. (2008). Lifestyle intervention, diabetes, and cardiovascular disease. The Lancet, 371 (9626), 1731–1733.

3) Herder, C., Peltonen, M., Koenig, W., Sütfels, K., Lindström, J., Martin, S., Tuomilehto, J. (2009). Anti-inflammatory effect of lifestyle changes in the finnish diabetes prevention study. Diabetologia,52 (3), 433–442.

4) Hublin, C., Partinen, M., Koskenvuo, M., & Kaprio, J. (2011). Heritability and mortality risk of insomnia-related symptoms: A genetic epidemiologic study in a population-based twin cohort.
Sleep, 34 (7), 957–964.

5) Kripke, D. F., Garfinkel, L., Wingard, D. L., Klauber, M. R., & Marler, M. R.(2002). Mortality associated with sleep duration and insomnia. Archives of General Psychiatry, 59 (2), 131–136

6) Tuomilehto,H.,Peltonen,M.,Partinen,M.,Lavigne,G.,Eriksson,J.G.,Herder,C., Lindstrom,J. (2009). Sleep duration, lifestyle intervention, and incidence of type 2 diabetes in impaired glucose tolerance: The Finnish diabetes prevention study. Diabetes Care, 32 (11), 1965–1971

7) Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. 2007 Sep;47(8):1184–8

8) Kundermann B, Krieg JC, Schreiber W, Lautenbacher S. The effect of sleep deprivation on pain. Pain Res Manag. 2004;9(1):25–32

9) Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep Res. 2007;16(1):85–95

10) Roth T, Roehrs T. Insomnia: epidemiology, characteristics and consequences. Clin Cornerstone. 2003;5(3):5–15