Sleep

Poor sleep increases the chances that you will experience:

• Pain: Sleep and pain are closely linked. It makes sense that pain interferes with getting to sleep or staying sleep. But there is even more evidence to show that poor sleep makes pain worse! In fact, consistently poor sleep can even contribute to the onset of chronic pain over the long term.
• Fatigue: Fatigue is one of the most common symptoms of painful conditions. The majority of people living with pain report significant fatigue that interferes with daily life. Fatigue can be experienced as mental (or cognitive) fatigue, physical fatigue, or emotional fatigue. Although fatigue is more than just sleepiness or tiredness from a lack of sleep, poor sleep can make you feel more fatigued.
• Mood: The link between mood and sleep is well established. Feeling anxious or depressed can make it harder to get good quality sleep. And poor sleep can make it harder to maintain a positive mood during the day. Long periods of poor sleep can also cause the onset of depression and anxiety.
• Ability to think clearly: People living with chronic pain often have problems with thinking, such as foggy or slow thinking, and problems with memory, concentration, or finding the right words when speaking. While these problems are often chalked up to having pain, sleep has a strong influence on thinking ability and links between poor sleep and performance on cognitive tests has been shown.

Getting enough sleep – and good quality sleep – can help you manage pain and feel more rested and energetic. If you are having trouble sleeping, you may be frustrated and confused about what to do. You should talk to your doctor if you find your sleep disrupted by a frequent urge to use the restroom, or if you feel your medication interferes with your sleep. Usually, a few simple adjustments in behavior can help improve sleep.

Your body contains many biological clocks that help to coordinate physical, mental, and behavioral processes throughout your body. The biological clocks typically run on a 24-hour cycle. Nearly every organ contains its own biological clock.

Your brain contains something called a “master clock” that coordinates all of the other biological clocks throughout your body.  The master clock is located in a part of the brain called the hypothalamus. The hypothalamus is closely connected to the eyes, so receives a lot of information about light and darkness. Therefore, the master clock is highly sensitive to light.

Circadian rhythm refers to the 24-hour cyclic pattern of a specific bodily process. There are circadian rhythms that regulate many different bodily functions.  For example, the circadian rhythm in gastrointestinal system causes a coordinated motility contraction of the colon, sometimes called a “mass movement,” every morning that pushes stool a long distance through the colon. For this reason, it is very common to have a large bowel movement in the morning and less common to have bowel movements later in the day.

The circadian rhythm that we want to focus on in this module is the one that regulates sleep.

Remember that the master clock coordinates the circadian rhythm and is very sensitive to light. In the evenings as it gets darker, your hypothalamus senses less light. This causes the master clock to release melatonin, which is a naturally occurring hormone that helps you fall asleep and stay asleep.

Because the master clock, and thus the circadian rhythm, is so sensitive to light, it can get thrown off if the light conditions are abnormal. Think about a time when you traveled somewhere that was several different time zones away from home. You probably had a difficult couple of days as your body adjusted to the new time zone. Many people feel kind of groggy or just “off” until their circadian rhythm adjusts to the new light schedule.

You may have heard that the fastest way to adjust to a new time zone is to get up as the sun is rising. Seeing sunlight in the morning helps to reset or calibrate our master clock for the new 24-hour period.

Unfortunately, we can also throw off the circadian rhythm with light from electronics, such as phones, computers, and television. If your master clock is sensing light late into the evening, it doesn’t start releasing melatonin when it should, making it more difficult for you to fall asleep or stay asleep.

The good news is that the circadian rhythm is typically pretty adaptable – meaning that we can use this information about light, melatonin, and 24-hour cycles to improve sleep quality.

To be clear, sleep is more complex than just circadian rhythms. You will probably need to make adjustments in several areas to improve your sleep quality and duration. But optimizing your circadian rhythm is the foundation for healthy sleep.

• Get up at same time every day (within a 15-30 minute range), even on the weekends.
• Try to get exposed to sunlight soon after you wake and throughout the morning. If you have trouble seeing sunlight in the morning because of work schedule, weather, or other issues, consider using light therapy for a brief period in the morning. (See Light Therapy for tips)
• If you feel that you need to nap during the day, try to do it in the early afternoon and try not to sleep longer than 30 minutes. Studies seem to indicate that naps impact sleep for some people more than others. If you find that you are napping on a regular basis, you may want to keep a sleep diary to see whether you have more difficulty falling asleep or whether you wake up more frequently. If so, try first to move the time of your naps earlier. If that doesn’t help, try setting an alarm for naps that you aren’t sleeping as long.
• Try to limit exposure to bright lights and sunlight in the late evenings.
• Avoiding electronic screens (phones, computers, television) for 30-60 minutes before bedtime can be extremely helpful. The type of light used in these devices is very stimulating to the master clock and suppresses natural release of melatonin, which can disturb your circadian rhythm.
• Going to bed at the same time every day is less critical than a consistent wake up time. But it is important to go to bed at a time that will allow you to get at least 7-8 hours of sleep before your wake-up time.

• Decrease the temperature slightly at night. Many people sleep best when room temperature is between 65-68.
• Try to make your bedroom a peaceful and relaxing space.
• Keep your room dark when trying to sleep. You may want to try blackout curtains if you have nearby streetlights or other neighborhood lights. If this is difficult, you could try to wear an eye mask.
• If you can’t keep your bedroom completely quiet because of noise in your house or neighborhood, consider trying a white noise machine in your bedroom which can drown out the more irregular noises. You may also try a fan or ear plugs.
• Try to use your bed only for sleep and sex so that your brain associates your bed with rest. Try to avoid other activities, such as reading, working, eating, or watching TV in bed.
• Make sure the padding thickness on your mattress feels comfortable. If you have pain or soreness, adjust your pillows or mattress to support those areas. For example, many people who prefer to sleep on their side find that placing a thin pillow between the knees helps keep their hips aligned which can lessen back pain.
• Consider keeping pets off the bed if they may wake you up or keep you awake when they move or make noise.

• Create a relaxing bedtime routine. Your body needs some time to wind down after the day’s activities. This could include reading, warm bath, gentle stretching, or relaxation techniques. (See Relaxation for tips)
• Getting regular physical activity and exercise can help your body fall asleep faster and stay asleep throughout the night. Some people find that vigorous activity in the late evening can make it harder to fall asleep. If this is true for you, try exercising earlier in the day and avoid strenuous activity in the evening.
• While a light snack may help you sleep, heavy foods and drinks may make it hard to fall asleep or stay asleep.
• Try to avoid caffeine in late afternoon and evening.
• Minimize alcohol in the evening. It may seem that alcohol helps you fall asleep faster, but it is likely to cause you to wake up more frequently during the night.
• Avoid tobacco/nicotine use. Any regular nicotine use, and particularly nicotine use in the late evenings, can cause difficult falling sleep or interfere with restorative deep sleep.

• Get out of bed if you are not asleep after 20 minutes. If you have not fallen asleep in this time, your body is not ready to sleep yet. Go into another room and do something quiet, such as reading or listening to music. Try to keep the lights dim and avoid using your phone or other electronic devices. Go back to bed when you start feeling sleepy.
• Try not to watch the clock. Watching the time pass and worrying about how much time you have left to sleep may make it more difficult to fall asleep. Turn your clock toward the wall so you can’t focus on the time.
• If you find that you are getting up to use the restroom several times per night, try to limit how much water or other beverages you drink in the evenings.
• If you lie awake at night with racing thoughts, try to jot down what worries you. Then, set aside time for the next day to think about the problems you wrote down and how to solve them. Problems that cause worry at night often seem more manageable in the daytime. Also, your mind may be better able to rest once it is not trying to keep a running list of all the things you need to think about the next day.
• Conditions like depression and anxiety can contribute to poor sleep if they are not adequately treated. Talk to your primary care provider about how to better manage these conditions if present.
• If you snore and wake up frequently overnight or feel unrested when you wake up in the morning, you should consider asking your primary care provider whether you can be tested for sleep apnea. Untreated sleep apnea contributes to poor sleep quality and increases your risk for heart disease, stroke, high blood pressure, diabetes, and depression.
• If you are using medications or supplements, talk to your primary care provider about how you may be able to change timing or dose of medications to optimize sleep. For example, some blood pressure medications can increase urination frequency, so taking these in the morning rather than evening can decrease need to get up to use the restroom overnight. Some medications that are used for pain or mood, such as gabapentin or amitriptyline, can cause grogginess. Taking these before bed rather than during the day may help you fall asleep or stay asleep.

Be patient. It takes time and effort to improve your sleep patterns, and many of these strategies may take several weeks to fully take effect. Don’t be discouraged by a bad night here or there. Symptom trackers can help you better monitor progress by seeing the overall trajectory rather than focusing on one or two tough nights. Symptom trackers can also help you identify patterns or factors that may be positively or negatively impacting your sleep, such as starting a new medication or new exercise routine. See Monitoring Progress.

MYTH:

“I should sleep whenever I get a chance.”

FACT:

Going to sleep and waking up at the same time every day helps your body learn a pattern of sleep

You may feel you have too much to do to set enough time aside to sleep each night. This may mean you are overdoing it and need more sleep than you are currently getting.

You may feel exhausted during the day and feel that you need to take a long nap to catch up. Some people find that naps that are late in the day or long (more than 30 minutes) can make it harder to fall asleep and stay asleep at night.

MYTH:

“I’ll be tired the next day if I change my sleep habits.”

FACT:

It’s true that when you change your sleep pattern, you may be a bit more tired at first.

Changing old habits and learning how to get a good, restful night’s sleep doesn’t happen immediately. Give yourself a few weeks to get used to the new pattern and for your body to adjust.

CBT-I from the United States Department of Veterans Affairs is an app for your mobile phone or tablet that can teach you strategies for improving your sleep Sleep on Monitoring symptoms