#57 Pain & Sleep-a double edge

Neuropathic pain, pain that is associated with dysfunction in the peripheral system, is commonly associated with comorbid sleep disturbances. Neuropathic pain can often be complex and is often chronic (lasts longer than 6 months) and can be exacerbated by comorbid conditions such as depression and anxiety. Research indicates that as pain intensifies, sleep gets worse, and as sleep gets worse, pain intensifies. This can create a vicious cycle where an individual’s pain can create a poor night’s sleep, and that poor night’s sleep may increase the intensity of pain felt the following day.

When managing pain and sleep disturbances, the focus is often on reducing the pain itself, using medication, heat therapy, physiotherapy or other modalities to manage or reduce the pain. The idea is that when you manage the pain, you decrease the sleep disturbances that are caused by the pain. However, focusing solely on pain management may not be enough to stop the cycle of pain and sleep disturbance. This is because oftentimes, sleep disturbances caused by pain may lead to un-managed sleep problems such as insomnia. Insomnia can occur when there is a complaint of difficulty falling asleep, staying asleep, or non restful sleep that leads to daytime impairment. If unresolved, insomnia can become a chronic condition when it occurs at least three nights a week and lasts longer than one month. In these instances, Cognitive Behavioural Therapy for Insomnia (CBT-I) is the recommended treatment option. CBT-I is the first line treatment for chronic insomnia and can be a great alternative to sleep medications. CBT-I can also be beneficial for those with chronic pain because when improving long-term sleep, there tends to be the added benefit of improved pain management.

WHAT IS CBT-I?

CBT-I is a non-pharmacological approach that focuses on both the psychological and behavioural factors that may contribute to an individual’s inability to sleep. This effective treatment approach may combine several of the following methods:

Stimulus Control Therapy:

• use techniques to reduce the arousal and improve the positive association between bed and sleep
• it’s important that your brain is cued to associate your bed and bedroom for sleep and intimacy only, therefore, the only activities that should be done in the bedroom are sleep and sex
• if unable to sleep within 20-30 minutes, it’s important to get out of bed (rather than lay in bed getting frustrated because this creates hyper-arousal and weakens the association that the bed is for sleep)

Sleep Restriction:

• the goal of sleep restriction is to increase the amount of good sleep, and reduce the amount of delayed sleep onset and nighttime awakenings
• sleep efficiency is improved by compressing the total time in bed so that it matches the patient’s total sleep needs (i.e. if it takes a patient about 2 hours to fall asleep, and they are laying in bed for a total of 8 hrs, then the sleep window may be restricted to 6 hrs)
• increases sleep deprivation and sleep drive to increase sleep efficiency/sleep quality
• this technique is temporary, and once the sleep begins to improve and become more solid, the sleep window is gradually increased until the patient’s sleep needs are met

Sleep Hygiene:

• involves developing and implementing behavioural lifestyle changes that help create a stable sleep routine
  • healthy sleep hygiene practices include:
    • regular physical activity
    • keep a routine bedtime and rise time
    • sleep only when sleepy
    • leave bedroom if unable to sleep within 30 minutes
    • avoid caffeine and nicotine 4-6 hrs before bed
    • use bedroom for sleep and intimacy only
    • avoid sleeping in or napping 8 hours before bed
    • develop a pre-sleep routine
    • avoid nighttime clock watching
    • avoid heavy snacking before bed
    • create a quiet and comfortable sleep environment
    • unplug from technology at least 2 hrs before bed

Relaxation Training:

• techniques such as diaphragmatic breathing, guided imagery, progressive muscle relaxation, or meditation can be used to reduce arousal and promote sleep
• useful relaxation resources include: Audible, Insight timer, Headspace, My Health Alberta Relaxation audio tracks

Cognitive Control Psychotherapy :

• utilizes methods of taking control of worries to reduce the effect of anxiety on your sleep
• change dysfunctional thought patterns that may be contributing to sleep-related anxiety

It is important to be aware that CBT-I alone can not cure your chronic pain, it can only reduce the cyclical nature of the relationship between pain and sleep. It is best to use a multidisciplinary approach when to comes to managing chronic pain, and to combine CBT-I with pain management techniques like physiotherapy, dietary modifications, and pain medication. It is also recommended that you consult with your doctor to determine which approach is best for your neuropathic pain needs.

WHERE CAN I FIND FURTHER INFORMATION ABOUT CBT-I?

• Centre for Sleep & Human Performance: https://centreforsleep.com/
• Canadian Sleep Society:  www.canadiansleepsociety.com
• National Sleep Foundation:  www.sleepfoundation.org
• AASM Sleep Education:  www.sleepeducation.com
• Dr. Jacobs: www.cbtforinsomnia.com
• Judith R. Davidson Sink Into Sleep: A Step-By-Step Workbook for Reversing Insomnia: https://www.amazon.ca/Sink-into-Sleep-Step-Step/dp/1936303388
• Charles M. Morin & Stephanie A. Silberman The Insomnia Workbook: https://www.amazon.ca/Insomnia-Workbook-Comprehensive-Guide-Getting/dp/1572246359

References:

• Argoff, C. E. (2007). The Coexistence of Neuropathic Pain, Sleep, and Psychiatric Disorders. The Clinical Journal of Pain, 23(1), 15-22.
• Davidson J. Sink Into Sleep A Step-By-Step Workbook for Reversing Insomnia. New York (NY): Demos Health, 2013.
• Meskill, G. J. Chronic Pain and Poor Sleep: A Vicious Cycle: https://www.ourcpc.com/learning-exchange/chronic-pain-and-poor-sleep-a-vicious-cycle/
• Silberman S., Morin, Charles. The Insomnia Workbook. Oakland (CA): New Harbinger Publications, 2008.