Sleep

Benefits of Sleep

Sleeping is as necessary to survival as breathing, eating, and drinking. People can cope without sleep for a short period of time, however long-term sleep deprivation can have many negative consequences on the brain and body.

Some ways sleep positively impacts our bodies:

  • Brain

    • Improved memory and concentration
    • Greater ease at learning new facts or skills
    • Improved appetite regulation through balanced hormones
    • Better clearing of waste products from the brain
  • Immune System

    • Improved immune system function
    • Improved response to medications and vaccines
    • Reduced susceptibility to illness
  • Stress & Mood

    • Psychological well-being and mood
    • Decreased stress hormones
    • Lower anxiety
    • Lower depression
  • Energy

    • Restored energy
    • Effect on thyroid and growth hormones
  • General Physical Health

    • Repair of injuries to muscles, bones, nerves, and other tissues
    • Increased growth
    • Decreased risk of heart disease, stroke
    • Decreased frequency and severity of headaches or migraine
    • Lower risk of diabetes
    • Reduced weight gain
  • Pain

    • Improved pain tolerance
    • Pain experience becomes harder to trigger (fewer flare-ups)
    • Lower pain intensity

Sleep quality and pain affect each other; pain can cause sleep problems, and sleep problems increase the risk of experiencing pain. With sleep disturbances, there is an increased likelihood of developing persistent pain, changes in pain thresholds, and muscle tension/fatigue.

In this module you will learn about: 

  • How sleep works
  • Relationship between sleep and pain
  • Sleep disorders
  • More issues caused by lack of sleep
  • Resources to create a more consistent sleeping schedule

 What Drives our Sleep?

  • There are two systems in the body that work together to make us sleep
    • Circadian rhythm
    • Sleep drive
  • These systems are guided by cues such as light and darkness, activity level, and routines

  • Circadian Rhythm

    • A biological clock in the brain that lines up with the 24 cycle of light/darkness in our day and night
    • Regulates when we feel sleepy
    • Special cells in the back of the eye send information on how bright it is to the brain
    • When it is darker, the brain makes melatonin, a hormone that makes us feel drowsy

    Although many factors may play a role, the two most powerful ways to set the body clock are: 

    1. Getting sunlight during the first hours of the day leads to earlier rise time/bedtime; getting daylight during the last hours of the day leads to later sleep and rise times. 
    2. Getting out of bed at a regular time so the body clock gets a more reliable daily reset. 
  • Sleep drive

    • The amount of pressure your body produces to go to sleep
    • Based on how much time you spend awake and active in a 24-hour period
    • A chemical in the body called adenosine builds up whenever you do activity and more adenosine makes the sleep drive stronger (left figure)
    • When you nap, you decrease your stores of adenosine and have less sleep drive (right figure)

    Some habits can also lead to less sleep or decrease the sleep drive:

    • Staying in bed after the alarm goes off
    • Sleeping in in the morning
    • Going to bed earlier than usual
    • Doing less activity because of how you feel (e.g. less physical activity, cancelling plans, calling in sick to work or an appointment)
    • Napping or trying to nap during the day (this uses up the adenosine you have produced)

Once we are asleep, we cycle through the 5 stages of sleep. Each cycle takes about 90-110 minutes, and we usually have about 4-5 cycles each night (i.e., during an 8-hour sleep). Each stage shows different characteristics and different brain activity occurs.

Stages of Normal Sleep (click on image or here to view) From: https://sleepcouncil.org.uk/how-much-sleep-do-we-need/

  • Cycle through the 5 stages of sleep.
  • Each cycle takes about 90-110 minutes
  • Usually 4-5 cycles each night (during an 8 hour sleep)

Experiencing all of these stages is important because each stage allows for different body and brain tissues to be restored. Often, fragmented sleep can lead to decreased time spent in stages 3, 4, and REM. This can affect how you feel pain.

 

The Relationship Between Sleep & Pain

  • 50-80% of people with persistent pain report trouble with sleep
  • Sleep quality and pain interact with each other; pain can cause sleep problems, and sleep problems increase risk for pain

Why is sleep important for pain management?

  • Sleep is essential for health and engagement in life
  • Benefits of sleeping well include:
    • Improved memory and concentration
    • Improved immune system function
    • Lower stress
    • More energy
    • Lower pain intensity
    • Improved healing
  • Restorative sleep allows the brain to clear waste products that accumulate during the day
  • These benefits work together to decrease pain experiences and help cope with pain

People with pain also feel less control over their sleep, worry more about lack of sleep affecting their health and exhibit greater sleep sensitivity. They’re more likely than others to say environmental factors make it more difficult for them to get a good night’s sleep. These factors include noise, light, temperature and their mattresses alike, suggesting that taking greater care of the bedroom environment may be particularly helpful to pain sufferers.

See National Sleep Foundation for more information on the relationship between sleep & pain. 

 

 

Common Sleep Disorders

Sleep disorders are a medical disorder of the sleep patterns. There are many people who may be sleep deprived but who do not have a sleep disorder. However, it is important to find out if you are dealing with a sleep disorder so you can get the right treatment. If you think you may have a sleep disorder, speak with your primary care provider. The most common pain-related sleep disorders are:

  • Insomnia

    • Insomnia is the most common sleep problem.
    • Most people have short term insomnia at some point in their lives.
    • It happens when people have trouble falling asleep or staying asleep even though they had a chance to get a full night of sleep.
    • Insomnia can have different causes, symptoms, and severity.
    • Insomnia can happen for one night, or may last weeks, months, or years.
    • Chronic insomnia is when it lasts more than three months

    There are many things people try and many changes people make to control their ability to sleep. Sometimes these things work, and sometimes they may become insomnia amplifiers leading to rigid routines that may not help. What can often occur is lost trust in the ability to sleep. Insomnia amplifiers including things like:

    • Changing your sleeping patterns
      • Spending too long in bed
      • Frequently changing when you go to bed and wake up
      • Daytime napping
    • Long-term use of medication or substances
      • Loss of trust in own ability to sleep
      • Alcohol, cannabis, nicotine, caffeine and many other drugs
      • Rebound insomnia when you stop using them
    • Forced relaxation
      • Useful in a stressful moment, but not when 'forcing' yourself to fall asleep.
      • Can increase anxiety when it “isn’t working”
    • Unhelpful habits meant to control sleep
      • Using electronics for distraction, such as TV watching
      • Social interaction, like reading emails or social media
      • Being overly active when you can’t sleep – getting up to work, eat, wander around, stretch
      • Mind games, clock watching
    • Making life-narrowing life changes
      • Strict routines
      • Reducing evening social activities
      • Avoiding morning activities
    • Narrowing your life and cutting out meaningful activities doesn’t necessarily help with sleep, and can actually make people feel more anxious and isolated. In turn, this anxiety can feed back into the insomnia.
  • Sleep-related breathing disorders

    • Obstructive Sleep Apnea

      • A disorder where your breathing stop while you’re asleep due to the passageway for air to go in and out of your lungs being blocked
      • Usually the airway is blocked by the tissue in the back of a person’s throat relaxing and narrowing the airway
      • Sometimes people will snore when this happens
      • During obstructive sleep apnea, the airway can become blocked repeatedly and the brain doesn’t get enough oxygen, and will wake you up briefly
      • Sleep apnea can be very dangerous since your brain is not getting enough oxygen

       Central Sleep Apnea

      • A disorder where your breathing repeatedly stops and starts during sleep because your brain does not send the proper signal to the muscles that control your breathing
      • Less common than obstructive sleep apnea
      • May occur as a result of other conditions, such as heart failure and stroke
      • Treatments may involve treating the existing conditions, or using a device to assist breathing or providing supplemental oxygen

    References for more information:

  • Circadian Rhythm Disorder

    • Circadian rhythm disorders occur when sleep times are not aligned with day and night
    • This can include jet lag and shift work syndrome
    • When someone has a delayed sleep-wake disorder, their internal clock is shifted later at night and in the morning (go to bed later, wake up later)
    • When someone has an advanced sleep-wake disorder, the opposite happens: they tend to have an early bedtime and wake up hours earlier than most people.
    • With delayed and advanced sleep-wake disorders, people usually sleep normally as long as they are able to get enough hours of sleep
    • Use of sleep aids such as melatonin as well avoidance of blue or white light closer to bedtime can help with anchoring your circadian rhythm

    Shift Worker Sleep Disorder

    • For individuals who work night shifts, rotating shifts or even early morning shifts, they are prone to developing this condition.
    • It can cause chronic sleep deprivation, in which a person never catches up on needed sleep and carries a “sleep debt” with them.
    • This sleep loss can cause problem in health, productivity and safety.

     Symptoms:

    • Excessive sleepiness when you need to be awake, alert and productive
    • Insomnia, or the inability to sleep when you need to
    • Sleep that feels unrefreshing or insufficient
    • Difficulty concentrating
    • Lack of energy
    • Irritability or depression


     

  • Sleep Movement Disorders

    • Sleep Movement Disorders

      • This group of sleep disorders consists of conditions that make your body move before or during sleep
      • Sleep movement disorders can make it hard to fall asleep or stay asleep, or to sleep restfully
      • Bruxism (grinding or clenching the jaw), leg cramps, and restless legs syndrome are the most common types of sleep movement disorders

       Restless Legs Syndrome

      • Restless legs syndrome is often described as a sensation of discomfort in the legs that is different than leg cramps or numbness
      • People sometimes describe it as itchy, crawling, burning, creepy, or throbbing
      • Usually people want to move their legs when they feel this sensation but do not feel the satisfaction that they were expecting
  • Hypersomnia

    Primary Disorders of Daytime Sleep Disorders

    • Excessive daytime sleepiness, excessive time spent sleeping, or trouble staying awake during the day.
    • Often fall asleep at times that are inconvenient or dangerous, such as at work or driving.
    • The most common disorders under this category is narcolepsy or idiopathic hypersomnia.

    Most Common Forms

    • Cataplexy is the loss in muscle tone, triggered by emotions such as laughter, surprise, fear or anger. This occurs when the person is awake, and causes feelings of weakness and a loss of voluntary muscle control, resulting in the immediate and full body collapse.
    • Excessive Daytime Sleepiness (EDS) is the persistent sense of mental cloudiness (brain fog), lack of energy, persistent drowsiness and extreme exhaustion which continues for prolonged periods of time.
    • Disrupted or fragmented nighttime sleep is sleep disrupted by periods of wakefulness, vivid dreams sleep talking and movement.
    • Hypnagogic (during sleep onset) or hypnopompic (during waking) hallucinations are vivid, realistic and often frightening dreams that occur on the edge of sleep and wakefulness.
    • Sleep paralysis is the temporary inability to move, occurring in the transition between sleep and wakefulness.

     

    Talk to your doctor if you think you are excessively sleepy.

    Resources for more information:

     

  • Parasomnias

    Parasomnias

    • Undesirable movements, behaviours, perceptions, or dreams that occur during sleep or arousals from sleep without conscious awareness.
    • This includes but is not limited to nightmares, night terrors, sleepwalking, confusional arousals, sleep talking, sleep paralysis, impaired sleep-related erections, and more.

     

    Night Terrors

    • Waking up abruptly in a frightened state from sleep
    • Often accompanied by crying or screaming, with an increase in heartrate and breathing, swearing or flushing of the skin
    • Though the individual may appear to be awake, the person is often confused and unable to communicate properly
    • Usually brief but can last up to 40 minutes, after which time the person lies down and appears to fall back asleep

     

    Sleepwalking (Somnambulism)

    • When the person appears to be awake and moving around with their eyes wide open but is actually asleep
    • Wake up with no memory of their actions, or make wakeup in the middle of an episode and appear confused of what happened

     

    Confusional Arousals

    • Occur when the person is awaked from a deep sleep during the first part of the night
    • This individual wakes up extremely confused, may cry or be completely inconsolable

     

    Nightmares

    • Vivid dreams during sleep that cause feelings of fear, terror and anxiety

     

    Sleep Paralysis

    • Individual feels that they are unable to move the body or limbs when falling asleep or waking up due to their muscles feeling paralyzed, even though they are awake

     

    REM Sleep Behaviour Disorder

    • Individuals act out dramatic and/or violent dreams
    • Involves a state of paralysis, however people move the body or limbs while dreaming

     

    If you experience, or are told you have experienced strange sensations or behaviours during sleep, please see your physician as soon as possible.

 

 

Healthy Sleep Habits

Daytime prep:

  • Try to get up at the same time each day.
  • Exercise in appropriate amounts during the daytime, and avoid exercise closer to bed time, or night.
  • Avoid caffeinated beverages, especially after noon. Caffeine lasts in your system for a long time and may interfere with your sleep.
  • Avoid naps or limit them to between 15-20 minutes.

Just before bed:

  • Make sure the bedroom is dark and quiet, and at a comfortable temperature.
  • Reserve the bedroom exclusively for sleeping and remove distractions such as TV, or other devices.
  • Relax or unwind and avoid work or other stimulating activities.
  • Avoid heavy alcohol use, heavy meals, and smoking.
  • Try light stretching exercises, such as yoga or tai-chi.
  • Try taking a warm bath, or a shower for relaxation.
  • Limit exposure to white or blue light close to bedtime 

Bedtime:

  • Try to keep a regular bedtime and a wake time.
  • If you are having trouble falling asleep for longer than 15 minutes: get out of bed
  • Do not stare at the clock. Set the alarm and turn it around such that you can see the time display.

Below are a number of ways to improve your sleep habits!

 

  • Protect your need for sleep

    • Most adults need 7.5-8 hours to function well
  • Maintain regular sleep hours

    • Your bedtime should be the same weeknights and weekends
    • Your wake up time should be the same on weekends and during the week
  • Limit naps

    • Napping may help daytime functioning, but too close to bedtime may decrease your need for nighttime sleep
    • Limit naps to 20-30 minutes, early in the afternoon
    • If you find that you can't fall asleep at bedtime, eliminating even short catnaps may help
  • Spend time to shift into sleep mode

    • Spend the last hour before bed doing a calming activity such as reading, stretching, warm bath
  • Avoid electronic devices last hour before bed and in middle of the night

    • The light from the screens of these devices stops your brain from making melatonin
    • Use a light filter to block blue light if you must look at a screen
  • Exercise

    • Physical activity helps with stress and overall sleep quality
    • Avoid doing vigorous exercise more than 3 hours before your bedtime
  • Meals and drinks

    • Limit eating big or spicy meals right before bed, as this can cause indigestion that can make it hard to sleep
    • Try a light snack 45 minutes before bed if you’re hungry.
    • Limit drinking fluids close to bedtime
    • Limit caffeine after 2 pm
  • Bed Association

    • Remove work materials, computers and televisions
    • Use your bed only for sleep and intimacy to strengthen the association between bed and sleep
  • Sleep Environment

    • Mattress should be comfortable and supportive
    • Keep bedroom cool
    • Keep it quiet
      • White noise/humidifiers/fans
      • Ear plugs
    • Keep it dark
      • Blackout curtains
      • Eye shades

    Try to get early morning sunlight to reset the circadian rhythm

  • Alcohol, Caffeine, and Nicotine

    • All may negatively impact sleep
    • Alcohol may help you get to sleep initially, but when it wears off it disrupts sleep
    • Nicotine and caffeine are stimulants
    • Nicotine has affect on sleep during withdrawal (sleep disturbances)

Sleep medications

  • Medications may be helpful in the short-term however with long term use:
    • Could reduce the quality of sleep by decreasing the amount of time spent in deep sleep
    • May interfere with alertness during the day, contribute to forgetfulness
  • Caution is required for driving, operating heavy machinery or other potentially dangerous activities
  • Note: some medications can have negative effects on sleep. They may disrupt your sleep, be a stimulant, or decrease how restorative your sleep is. These medications include:
    • Diuretics
    • Some antidepressants
    • Cold preparations
    • Antihistamines
    • Opioids
    • Steroids
    • Stimulants

More Information:

Non-pharmacological interventions to help with sleep

Here are a few common therapies/techniques that may help improve your sleep.

 

  • Cognitive Behavioural Therapy for Insomnia

    • Sleep can be affected by expectations, thoughts, worries, and stress.
    • Cognitive behavioural therapy strategies can help you to change your behaviour and your thinking patterns around sleep.
      • Behaviour changes can include sleep hygiene strategies, strictly ensuring you only use your bed for sleep and sex, and sleep efficiency training.
      • Thinking changes can include using coping thoughts and changing your beliefs about sleep.
    • Cognitive behavioural therapy is often led by a health care professional and is often done in one-on-one settings, or sometimes in a group.
    • Ask your doctor about whether this may be a good option for you.

     

  • Relaxation techniques

    Relaxation strategies such as deep breathing, guided imagery, and progressive muscle relaxation can help you feel calm and release body tension before you go to sleep. These can be done in a quiet place or in your bed lying down. These strategies turn on a part of your body’s automatic nervous system called the “parasympathetic nervous system” which helps you to feel calm, relaxed, and safe.

     

  • Sleep efficiency training

    • Sleep Restriction Therapy

      • Sleep efficiency refers to the quality of sleep you get
      • Sleep Restriction Therapy is a form of Cognitive Behaviour Therapy (CBT) where the goal is to reset the circadian rhythm
        • The goal is to form an association between bed and sleep.
        • Nothing is to be done in bed other than sleeping; no phone, reading, watching TV, etc.
        • If you don’t fall asleep within 20 minutes, you must get up and keep yourself occupied until you are tired enough to try falling asleep again.
        • You must wake up at the same time every day, regardless of how much sleep you got the night before.
        • After a few weeks of following this routine, you will begin to have a better grasp of your sleep schedule. With practice, you will be able to increase the amount of sleep you get per night, if you wish to.
      • If you have 9 hours of sleep and still feel unrested, you may not be getting good quality sleep
      • When it comes to sleep, quality is better than quantity. Sleep efficiency training can help you get a higher quality sleep.

       To figure out your sleep efficiency, calculate how long you are in bed vs. how long you are actually sleeping. Your goal should be to be in bed for only 30 minutes more than you sleep.  (Carney, 2009)

       Remember, one of the keys to healthy sleep habits is to associate "bed" with "sleep" and not too many other activities.

    Try our SLEEP EFFICIENCY TRACKER to make these calculations

     

     

     

  • Coping Thoughts

    Here are a few examples of coping thoughts that can help decrease worry and stress around sleep:

    • “I have a plan to do an enjoyable activity if I wake up, so waking up will be okay.”
    • “I’ll get a better sleep tomorrow if I make sure I get out of bed on time in the morning.”
    • “If I take a nap, I may or may not feel better after, and I will have a worse time sleeping tonight.”
    • Think about your own coping thoughts: _________________________________________________
  • Sleep tracking

    The first step is knowing where to target your actions to improve your sleep. There are a number of ways you can learn more about your sleep quality and sleep habits.

     

    Apps and Smart Wearable Devices

    There are many apps available that can be used to track your sleep. They use a smartphone or wearable device, such as a smart watch, to monitor movement and sounds and give you information on your sleep patterns. The most commonly used ones are:

    • iOS & Android app: “Sleep Cycle Alarm Clock”
    • FitBit Smart Watch: Sleep Tracker

     

    Please speak with a sleep specialist to determine which specific app would work best for you.

     

    Polysomnography/Sleep Study

    A sleep study, or polysomnography, is often recommended if you or your doctor suspect that you may have a sleep disorder. This is a study of your sleeping that takes place in a sleep laboratory. You will have electrodes placed around your head to monitor your brain activity while you sleep. Movement and times you wake up will also be tracked. This may sound strange, but a sleep study is not painful and can provide useful information. This information will be used to recommend possible treatments to improve your sleep.

     

    Sleep Log

    A sleep log is the most low-tech way to track your sleep. You use a sleep log to write down a variety of details about your sleep, including what time you went to bed, how often you woke up in the night, and your quality of sleep. You can see an example of a sleep log worksheet below.

     

    • How often and when do I fill out the sleep log?

    It is necessary for you to complete your sleep log every day. If possible, the sleep log should be completed within one hour of getting out of bed in the morning.

     

    • What should I do if I miss a day?

    If you forget to fill in the log or are unable to finish it, leave the log blank for that day.

     

    • What if something unusual affects my sleep or how I feel in the daytime?

    If your sleep or daytime functioning is affected by some unusual event (such as an illness, or an emergency) you may make brief notes on your log.

     

    • What do the words “bed” and “day” mean on the log?

    This log can be used for people who are awake or asleep at unusual times. In the sleep log, the word “day” is the time when you choose or are required to be awake. The term “bed” means the place where you usually sleep.

     

    • Will answering these questions about my sleep keep me awake?

    This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate.

  • Common misconceptions

    Common misconceptions about sleep

    The following are a few common misconceptions that people have around sleep:

    • Having trouble sleeping means I should try harder
    • I should try to catch up on sleep tonight if I slept badly last night
    • I should always sleep at least 8 hours per night
    • Sleeping poorly one night will mean I can’t function or do anything the next day
    • A bad night’s sleep happens because I slept badly the night before
    • Sleeping poorly one night has serious consequences

     These beliefs are either exaggerated or false, yet many people hold them to be true. These beliefs can interfere with trying or following through on strategies for changing sleep habits and thoughts about sleep. If you notice you have any of these beliefs, see if you can gently challenge the belief – for example, if you believe that a poor night of sleep will mean you are unable to function the next day, see if you can think of any times you were able to do what you needed to do despite poor sleep.

     The following are a few examples of coping thoughts that can help decrease worry and stress around sleep:

    • “I have a plan to do an enjoyable activity if I wake up, so waking up will be okay.”
    • “I’ll get a better sleep tomorrow if I make sure I get out of bed on time in the morning.”
    • “If I take a nap, I may or may not feel better after, and I will have a worse time sleeping tonight.”
    • Your own coping thought: _________________________________________________

 

Key concepts

 

  • Tracking your sleep with a sleep study or sleep log is the first step to improving sleep
  • Sleep habits are the factors that affect how well you sleep
  • Sleep strategies can target your sleep routine, environment, thoughts and body sensations
  • Sometimes medication can help sleep symptoms in the short term, but it is not effective at improving sleep in the long term (after about 4 weeks)
  • Relaxation strategies such as deep breathing, imagery, and progressive muscle relaxation are helpful ways to calm yourself before sleeping

Notice any false beliefs you have about sleep and come up with coping thoughts to reduce stress and worry about sleep

Useful Resources

Reading:

  • No more sleepless nights, by Peter Hauri PhD
  • Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety or Chronic Pain by Dr. Colleen E Carney, PhD
  • The Insomnia Workbook, by Stephanie Silbernman PhD
  • The Feeling Good Handbook, By Dr. David Burns
  • The Anxiety and Phobia Workbook, by Edmond Bourne PhD

 Online Resources for Cognitive Behavioural Therapy (CBT-I)

 Group CBT sessions

  • Please ask you doctor to evaluate if group or in-person CBT is an option for you

Conclusion

  • Sleep is necessary for good health and day to day functioning
  • Poor sleep and pain are highly related, and both can negatively affect thinking, concentration and memory
  • Several environmental factors, behaviours and medications can also affect sleep quality
  • Better sleep quality may lead to improvements in pain
  • Consider setting a goal around one strategy to improve sleep
  • If you find concerning anything about your sleep experience, seek professional help

Special thanks to Dr. Mandeep Singh and Mihal (Michelle) Esterlis for contributions and review of content.

 

 

76 Grenville St. Toronto, ON M5S 1B2 Canada

TAPMI Hub Clinic

Phone: 416-323-6269 Office Fax: 416-323-2666 Hours: 8:00 a.m. – 4:00 p.m. Monday – Friday

Administration

Dr. Tania Di Renna, Medical Director William Cachia, Administrative Director