Breaking the cycle of chronic pain and insomnia
Chronic pain can cause sleep disorders
Patients suffering from chronic pain often find
that their problems are compounded by the additional
difficulties that come with insomnia and sleeping disorders.
Of those who report experiencing chronic pain (about
15% of the general U.S. population and 50% of the elderly),
approximately 65% report having sleep disorders, such
as disrupted or non-restorative sleep.
Back pain is the most common type of
chronic pain problem, and is the most prevalent medical
disorder in industrialized societies. Not surprisingly,
individuals with chronic back pain problems frequently
report significant interference with sleep. In a recent
study, it was found that approximately two-thirds of
patients with chronic back pain suffered from sleep
disorders. Research has demonstrated that disrupted
sleep will, in turn, exacerbate the chronic back pain
problem. Thus, a vicious cycle develops in which the
back pain disrupts one’s sleep, and difficulty
sleeping makes the pain worse, which in turn makes
sleeping more difficult, etc.
Pain diminishes both sleep quantity and quality
The term “insomnia” includes all types
of sleeping problems, such as difficulty falling asleep,
difficulty staying asleep, and awakening earlier than
desired. Of all medical conditions, pain is the
number one cause of insomnia. With chronic pain
problems, difficulty falling asleep is one of the most
prevalent types of sleep disruption. However, awakening
during the night and awakening earlier than desired
are also frequent problems. Research surveys of those
with chronic pain problems have found that 65% report
that they are awakened during the night due to pain
and 62% report waking too early due to pain. In addition,
many patients with chronic back pain problems do not
feel “refreshed” in the morning when they
awaken, a sleeping problem termed “non-restorative
sleep.”
Difficulty falling asleep
Chronic pain can impact sleep in a number of
ways. To understand how a pain problem can make it
difficult to fall asleep, it is helpful to think
about the process associated with going to sleep
for the night. In getting ready for bed, it is common
to try and eliminate all distractions or other influences
in an effort to “relax” and begin to
fall asleep. This may include quieting the room,
turning off the lights, eliminating any other noises,
trying to get comfortable, and beginning to try and
fall asleep.
However, this “quieting” of
one’s environment can cause problems for the
chronic back pain sufferer since the only thing left
for the brain to focus on is the experience of the
pain. Patients will often report that one of their
primary pain management tools during the day is being
able to distract themselves from the chronic back
pain problem by staying busy with other tasks (e.g.,
reading, watching television, engaging in hobbies
or crafts, working, interacting with others, etc.).
When trying to fall asleep, however, there are no
other distractions available to focus on except for
the pain. In many cases, one’s perception of
the pain actually increases when attempting to fall
asleep. The longer falling asleep is delayed, the
more stressful the situation becomes.
Difficulty sleeping through the
night
In addition to difficulty falling asleep, chronic
pain patients also report awakening frequently during
the night. Research has demonstrated that individuals
experiencing chronic lower back pain may experience
several intense “micro-arousals” (a change
in sleep state to a lighter stage of sleep) per hour
of sleep, which lead to awakenings. Thus, the chronic
pain problem can be a significant intrusion into
a night’s sleep and disruptive to the normal
stages of sleep. This problem is often the cause
of “non-restorative sleep.” Individuals
with chronic pain often experience less deep sleep,
more arousals and awakenings during the night, as
well as less efficient sleep. Thus, the quality of
the sleep is often light and unrefreshing. This non-restorative
sleep pattern can then cause diminished energy, depressed
mood, fatigue, and worse pain during the day.
Pain and sleeping problems need to be treated together
A sleeping disorder associated with chronic back
pain should always be addressed as part of a multi-disciplinary,
chronic pain treatment approach. As with any symptom
of a chronic pain syndrome, one should not attempt
to treat the sleep disruption in isolation without
taking into account proper treatments for the chronic
back pain problem that is part of the cause of the
sleeping problems. Many behavioral and psychological
approaches to chronic pain treatment will also help
with the symptoms of sleep disorder, and one should
not be too quick to rush to medication solutions for
insomnia.
Behavioral approaches can be quite effective
in helping improve the quality of one’s sleep
when they are practiced on a consistent basis. Certainly,
these methods should be attempted first since they
are safe and without adverse side effects. If they
are not completely effective, then it may be appropriate
to consult with a physician about medications as an
adjunctive measure. When choosing a medication to help
with sleeping problems, it is important for patients
to talk with their doctor about other medications that
they are taking for the chronic pain problem as well
as other medical conditions.
Treating a sleep disorder involves attacking
the situation from a number of different standpoints,
including:
-
Pain and other physical symptoms. Addressing
the source of the pain.
-
Sleep hygiene. Practicing behavioral techniques
that can help improve an individual’s sleep.
-
Psychological approaches. These may include
techniques such as relaxation training, hypnosis,
and deep breathing.
-
Sleep medications. Appropriate medications
specifically designed to help with sleep.
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