Pain and Sleep

Introduction

Sleep and pain problems are among the most common complaints in our society and, not surprisingly, they often occur in the same person. Painful conditions such as backache, osteoarthritis, rheumatoid arthritis, headache, and fibromyalgia can make it hard to sleep. When you can’t sleep well, you may find your pain, headaches, and fatigue getting worse.  Studies have shown that several nights of disturbed sleep in healthy people may cause not only sleepiness, but also generalized muscle aching and fatigue.

In this article, we will review a number of ideas related to sleep and pain.  These will include:

  • an overview of the stages of sleep
  • why sleep is so important to your health and well-being
  • the possible causes of sleep disturbances
  • what treatment options are available

Sleep is defined as the natural cycle of hours when your mind quiets, you are not conscious of the world around you and the many functions of your body are restored. Sleep is a complex process that happens in stages. There are many processes in your body that need a regular sleep-wake cycle in order for you to be healthy. These processes are important in fighting infection, healing your injuries, and even for learning new information. Proper sleep is absolutely necessary for the normal function of your body. Sleep disturbances can have significant and serious consequences.

Anatomy of Sleep

The circadian rhythm is a built-in cycle of sleep and wake times. It is one of several regular changes that occur in your body including changes in temperature, heart rate, blood pressure, hormone secretions, and lung function. The internal cycles are controlled by a group of nerve cells called a circadian pacemaker. This pacemaker uses parts of the retina (in the back of the eye) and a small organ in the brain called the hypothalamus to work. Humans have a biological clock that runs in a 24-hour cycle. Sunlight resets this clock on a daily basis.

The Human Sleep Cycle

There is a lot of difference in mammals’ need for sleep. Daily sleep time for humans is approximately seven to eight hours. An owl monkey needs 17 hours a day. A bat needs 20 hours a day. Sleeping too little or too much can be harmful to your health.

Human sleep occurs in cycles that are about 90 minutes long. There are five stages of sleep within each sleep cycle. These stages have two separate parts, non-rapid eye movements (NREM) and rapid eye movement (REM). These stages can be seen as brain wave activity recorded using an electroencephalogram (EEG).

NREM sleep is the lighter stage of sleep. Your body may move a little bit, but your mind is quiet. NREM is divided into four stages, with each stage of sleep getting deeper. REM sleep is deep sleep that is more refreshing. This is because there is total muscle relaxation except for bursts of rapid eye movements. The brain is active in REM sleep and dreaming occurs in this stage of sleep. Ideally, 20 to 50 percent of an adult’s sleep should be in REM sleep. During this phase of sleep, there may be irregularities of the heart and breathing. These can be recognized by monitoring the heart with an electrocardiogram (ECG). REM sleep has been described as a very active brain in a paralyzed body. As sleep continues, the time spent in NREM sleep is less and the amount of time in REM sleep increases. The last third of the night is mostly REM sleep. It is linked to the circadian rhythm of body temperature. There are age-related changes that are predictable. Infants usually start the sleep cycle with REM sleep. As we approach age 65 and older, less time is spent in REM sleep.

Sleep Disorders

Some sleep disorders are known to have genetic causes. Others are caused by illnesses such as Parkinson’s disease, depression, lung disease, or heart failure. Other sleep disorders have an unknown cause. There are several common sleep disorders:

Sleep Apnea: When a person stops breathing for a minimum of 10 seconds during sleep it is called an apneic episode. If you have more than five apnea events in an hour, you are diagnosed with sleep apnea. Oxygen level in the blood or tissues is also important when making the diagnosis of sleep apnea. Oxygen levels at 95 percent and above are normal. In sleep apnea, levels may drop to 80 percent or lower. Levels below 70 percent are considered dangerously low. When this low, the heart may beat irregularly and you can be at risk of cardiac arrest, and death.

Central sleep apnea is the interruption of breathing during sleep. The cause may be unknown. Or it can be caused by medications such as opioids (narcotics). Other causes can be heart failure, stroke, renal failure, lung disease, or being at high altitudes.

Obstructive sleep apnea (OSA) is caused by closing of the airway when air should be moving into the nose, mouth, and lungs. It may be as common as two to four of every 100 adults, and three out of every 100 children.

Narcolepsy: This is the name given to excessive daytime sleepiness without troubled sleep during the night. It is diagnosed when a person can fall asleep really quickly, and be in REM sleep in 8 to 10 minutes. Falling asleep while driving, hallucinations while sleeping, and sleep paralysis may occur. Narcolepsy appears to be genetic. Narcolepsy is treated with medications.

Sleep-related movement disorders: These conditions include restless legs syndrome (RLS) and periodic limb movement disorders (PLMD). RLS is described as a strong, nearly uncontrollable desire to move the legs. The sensations are worse at rest and occur more frequently in the evening or during the night. Walking or moving the legs relieves the sensation.

By contrast, PLMD is a pattern of involuntary movements which are often rhythmic, that can interrupt sleep. Possibly up to 40 percent of persons over 65 years of age may have PLMD.

Insomnia: This is a general term that simply means having difficulty falling asleep or staying asleep, or getting sleep that is not refreshing and restorative. It happens in as many as 30 percent of Americans. Symptoms of insomnia — aside from difficulty sleeping — include daytime exhaustion or fatigue, lack of energy, lack of concentration, forgetfulness, irritability, and depression. Insomnia can be caused by many different conditions. It happens more frequently as we age, particularly after 60. It may be caused by stress, depression and anxiety, or mental illness. Noise or extreme temperatures in the environment can also cause insomnia. Other causes of insomnia can be shift work, jet lag, nighttime activity schedules, and medication side effects. Use of alcohol, tobacco, and illicit drugs may interfere with sleep. A person with insomnia may also have one of the other sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome.

In addition to the sleep disorders noted above, we should also note that some unusual behaviors can occur during sleep as well. These might include sleepwalking, sleep talking, tooth grinding, and other physical activities. This night time activity can get in the way of normal sleep cycles. Sleep related tooth grinding is called bruxism. Clenching of the teeth may cause tempomandibular joint pain and/or wearing down of the teeth. An appliance similar to a mouth guard or retainer may be used to help stop the damage to your teeth from grinding.

Symptoms of Sleep Disorders

What does a sleep disorder feel like? Sleepiness is the most common symptom in people with a sleep disorder. Sleepiness is caused by the decrease in the amount and quality of sleep, as well as disruption of the circadian rhythm of the body.

Fatigue and not feeling refreshed after sleeping, may be signs you have a sleep disorder.

Snoring and stopping breathing while sleeping are other symptoms of a possible sleep disorder. Also, sleep disorders may be associated with many chronic illnesses such as high blood pressure, heart attacks, stroke, headache, or depression.

There are many processes in the body that rely on the sleep-wake cycle. These processes are important in fighting infection, healing the body, and allowing processing of new knowledge or information. Sleep disturbances can have significant and serious consequences. Slower reaction times may make driving safely a problem. Poor balance, foggy thinking, and forgetfulness are also noted in persons with sleep disorders. Mood disorders (irritability or depression), a lack of motivation, and just not enough energy may also be symptoms of chronic sleep problems.

Diagnosis of Sleep Disorders

Diagnosis begins with a complete history and physical examination. Your doctor will ask you several questions to determine if your symptoms call for a sleep study. You may be asked to fill out a questionnaire about snoring, sleepiness, stopping breathing during sleep, unwanted leg movements, medications you are taking and such.

Your doctor may do a physical exam. An examination of your nose, mouth, throat, and lungs is usually included. Your doctor may request that you have a chest x-ray. The x-ray is to check for abnormalities of your lungs, or to measure your heart size. There are doctors who specialize in sleep medicine. You may be asked to be evaluated by one of them.

A polysomnogram is a procedure that is used to diagnose sleep disorders. It is done at a sleep laboratory or center. It is a way to record and measure what is going on during sleep. It can measure biological functions as well as body movement. Information is gathered from a set of electrodes taped to your skin. Wires from the electrodes carry signals to a monitoring device where they are recorded. The doctor then interprets the information. There are no needles. The electrodes measure electrical activity and do not cause an electrical shock.

The sleep laboratory consists of private rooms with beds. The sleep room is well insulated and temperature is kept comfortable. You may be allowed to wear your usual sleep clothes. You will be given a buzzer to alert the sleep study technician if you need to get up or get uncomfortable for any reason. Testing in the sleep study center may also involve seeing how long it takes to fall asleep while reading or resting as when taking a nap.

Brain wave monitoring is done with several electrodes placed on the surface of the skull. These electrodes monitor and record brain wave activity. It can tell the different stages of sleep and when you are awake. A stretchy belt called a strain gauge is placed around your chest to measure chest movements. A tool called an oximeter can read the amount of oxygen and carbon dioxde in your blood by shining a special light into your skin, usually your fingertip or ear lobe. Normal oxygenation is 95 to 100 percent. In sleep apnea, levels may drop to 80 percent or lower. All these measurements are used to decide if you have a sleep disorder.

Treatment of Sleep Disorders

Nonsurgical treatment options:

Treatment of insomnia can include nutritional supplements, herbs, aromatherapy, exercise, prescription medication and behavioral therapy. Psychotherapy may be helpful in decreasing stress and anxiety. Quite often, changes in habits are all that is needed to improve sleep. Poor sleep habits include spending too much time in bed or having an irregular sleep routine. Not getting enough bright-light exposure during the day and not maintaining your physical fitness with regular exercise will make it difficult to sleep. Sleeping in an environment that is too bright, too noisy, or too hot or cold can cause sleep problems. Drinking alcohol or caffeine too close to bedtime can also interfere with sleep. Treatment of depression is also important to consider.

Behavioral treatments often mean changing the way you act or think. You may need to learn how to slow down. Your fight or flight response can interfere with proper sleep. When your nervous system is on high alert, it is especially difficult to fall asleep. Reducing stress, doing relaxation exercises or other soothing activities can calm your nervous system. Changing what you believe about yourself and your sleep can also be helpful. In other words, as long as you think of yourself as someone who can’t get to sleep, you are more likely to find that to be true. Thinking of yourself as learning how to sleep well is a more useful way to making the changes you want. There are many simple ways that sleep can be improved. The following tips may be helpful for anyone with sleep problems.

1. You need to feel warm to be able to relax into sleep. Exercise can increase your body temperature. When vigorous enough, exercise can help you release endorphins, which are chemicals that act like morphine, a pain medication. A hot bath or a shower will also warm you up. A hot drink can work too. It is recommended that you try to increase your body temperature within two hours before bedtime.

2. Your bedroom should be a comfortable temperature, quiet, and dark. If there are things that are out of your control such as a noisy neighbor or animal, try using earplugs. Eye coverings help with unwanted light.

Bedtime rituals such as a bath, or listening to soothing will calm your body’s alertness. Reading for pleasure can be a good choice as long as the story isn’t too exciting.

3. Stress reduction and relaxation improve sleep. Set aside a time when you pay attention to what is worrying you that is a few hours away from bedtime. Do your worrying for the day, then set it aside. As you well know, the worries will be there for you to come back to at any time! Just don’t visit them at bedtime. Relaxation can include deep breathing exercises. Progressive muscle relaxation involves slowly tensing and releasing muscles. You usually start with muscles of the face, then neck. You gradually work your way down through your whole body right to your toes until you feel fully relaxed. Meditation, prayer, imagery, and listening to soothing music are other methods to help reduce stress.

4. Having a regular sleep schedule is important. Wake and get up at the same time each morning, including weekends, even after a poor night’s sleep. This will help you reset your internal rhythm.

Daytime naps longer than 20 minutes should be avoided. If you’re having trouble falling asleep at night, get out of bed. If you are awake in bed for more than 20 minutes, get up and go to another room for a little while. Do not watch TV in bed. The bed should be used only for sleep and sex. Too much time in bed causes interrupted and shallow sleep.

5. A warm drink or small snack before bedtime can help you sleep. Heavy meals late in the evening should be avoided. Exposure to sunlight is important for your daily rhythm. Spend some time outdoors especially soon after awakening up. Talk to your doctor about the use of bright light therapy to help regulate your sleep/wake cycle. You can also buy a light that will come on gradually to wake you gently, imitating dawn.

6. If you smoke, it is time to quit! Withdrawal from nicotine begins two or three hours after smoking. This can interrupt sleep. Avoid alcohol before bed. Although it may help you fall asleep, sleep is otherwise interrupted. Also, avoid caffeine, especially after the middle of the afternoon. It’s best to stop drinking caffeinated drinks altogether. You may have to taper off of caffeine. Most people will have symptoms of withdrawal. These could include headache and fatigue. Drinking at least 8 glasses of water every day will help withdrawal symptoms.

7. Avoid medications that may interfere with either falling asleep or staying asleep. Some medicines for pain may slow down your breathing during sleep. This can cause a Kind of alarm to go off in your brain that makes you wake up. Aromatherapy is the use of scents such as lavender, chamomile, or vanilla that help to quiet the nervous system. These may be sprayed on bedding. Oils may be placed under your nose, or on your chest, or used in the bath.

8. Allergies can cause swelling and narrowing of the airway. This can block part of your airway and contribute to sleep apnea. Ask your doctor about treatment of allergies. A mixture of water with a little bit of salt can be used to rinse the lining of your nose and sinus tissue. This helps to shrink swollen tissue. It also helps to flush pollen and other allergens. Humidifiers in dry climates may also help soothe the lining of your nose and sinuses.

9. Lose weight, particularly if you have sleep apnea. You may be asked to see a nutritionist to help with weight loss.

10. Change in sleep position can also make a difference. You may have more trouble breathing easily while lying on your back. Sleeping on your sides can help this. There are monitors and alarms you can use to remind you to stay in the position that works best. Some people have sewn a small ball into the back of their pajamas.

11. Dental appliances or retainers help hold your tongue and jaw forward during sleep. This will keep the airway open. Dental appliances are also used to treat bruxism, or grinding the teeth at night.

12. Continuous positive airway pressure (CPAP) is the most common treatment for sleep apnea. It is a breathing machine. A CPAP machine is a small machin to sit on your nightstand. It has a hose that attaches to a mask that usually covers the nose. The maar this while sleep. Room air is blown through the nose, although some people may also require oxygen at night. Your

Getting used to the CPAP machine is not always easy. Some people may experience anxiety from having the mask placed over the face. Others may not like the way it looks. It may take encouragement to help you deal with the changes you need to make to get a good night’s sleep. If you still have sleepiness or insomnia after using CPAP or after making several lifestyle changes, your doctor may need to consider more aggressive treatment.

Surgical treatment options:

Other treatments for sleep apnea are surgical. If you have trouble breathing through your nose, the surgeon may decide to cut away some of the soft tissue in the nose. Sometimes straightening the septum (cartilage) that divides the nose into two parts is also helpful.

If your airway is small, especially when the soft palate (top of the mouth) and the tongue relax during sleep, it may help you to have surgery to reshape that area. Excess tissue such as the tonsils, adenoids, and uvula are removed. These surgeries are usually performed by an otolaryngologist, or ear, nose, and throat (ENT) surgeon.

Sometimes surgery to change the structure of the jaw or face is considered. Ventilators or mechanical breathing machines are needed for some extreme cases of central sleep apnea. Air is blown from the ventilator through a hole in the neck called a tracheostomy. A tracheostomy is the operation used to make a small opening in the trachea or windpipe. A small cut is made by a surgeon in the front of the neck. A tracheostomy will mean less decreased air flow in the nose, mouth, and throat. During waking hours the tube is plugged to allow normal breathing. At night, a tube is inserted that is then connected to a ventilator or breathing machine

Summary

Regular follow up with your doctor or therapist is recommended to help make transition into lifestyle changes easier. Trying out different ideas for relaxation and other changes you are trying to make can take some coaching and support. The staff at the sleep center or the staff at the medical supply store is helpful in answering questions about equipment. They may also be able to help with making adjustments in equipment that make sleep better. It may take several weeks or months to adjust to using machines when sleeping.

There are many ways to help you have deep refreshing sleep. It is important to try all the ways you can help yourself first. Some things — like quitting caffeine and tobacco, not eating big meals at night, losing weight and getting exercise — you are in charge of doing for yourself, with the support of your health are team and family and friends. If these things are not enough, your doctor can help you with certain machines, like special lights that imitate dawn to wake you gently, or CPAP machine to make sure you are getting enough air. As a last resort, you and your doctor might think about surgery. When you are getting good sleep, many of your other medical problems such as blood pressure, weight, fatigue, and depressed mood have a better chance of getting better too. Regular nights of good sleep will help your experience of pain be easier to deal with.

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